Dental Hypotheses

: 2017  |  Volume : 8  |  Issue : 3  |  Page : 61--64

Effect of massage on the success of anesthesia and infiltration injection pain in maxillary central incisors: Double-blind, crossover trial

Roohollah Sharifi1, Saber Khazaei2, Hamid R Mozaffari3, Seyed M Amiri4, Pedram Iranmanesh2, Seyed A Mousavi2,  
1 Department of Endodontics, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Department of Endodontics and Dental Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Oral Medicine, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
4 Department of Biostatistics and Epidemiology, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran

Correspondence Address:
Saber Khazaei
Dental Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, (81746-73461)


Introduction: Pain control is important during dental treatments since the lack of sense of pain causes less emergency events, less extra injections, and increased patient’s trust. Infiltration injection in the anterior maxilla was considering one of the most painful injections. The aim of this study was to investigate the effect of local massage on the success of anesthesia and infiltration injection pain in maxillary central incisors. Materials and Methods: This double-blind, crossover trial was conducted among 30 participants by injection with and without “massage before the injection” over two sessions with an interval of 2 weeks. The injection pain in both methods was measured immediately after injection by Visual Analogue Scale (VAS) at three times of needle insertion, 5 seconds after injection, and needle withdrawal. The success rate of anesthesia was determined 5, 15, and 30 minutes after injection by electrical pulp tester. Results: The mean scores of VAS at three times with and without the massage at three times were not statistically significant (Wilcoxon, P > 0.05). However, the mean score of VAS in injection with the massage were lower. The success of anesthesia in injection with and without the massage at intervals 5, 15, and 30 minutes after injection was not found to be significant (McNamara, P > 0.05). Conclusion: Massage before injection had no effect on the success of anesthesia and injection pain.

How to cite this article:
Sharifi R, Khazaei S, Mozaffari HR, Amiri SM, Iranmanesh P, Mousavi SA. Effect of massage on the success of anesthesia and infiltration injection pain in maxillary central incisors: Double-blind, crossover trial.Dent Hypotheses 2017;8:61-64

How to cite this URL:
Sharifi R, Khazaei S, Mozaffari HR, Amiri SM, Iranmanesh P, Mousavi SA. Effect of massage on the success of anesthesia and infiltration injection pain in maxillary central incisors: Double-blind, crossover trial. Dent Hypotheses [serial online] 2017 [cited 2021 Oct 17 ];8:61-64
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The pain control during dental treatments is important when we know in most cases performing appropriate and correct treatment is impossible without topical anesthesia techniques. It is evident that more is the success rate of injection, less is the incidence of emergency events. The sense of pain is also reduced during dental procedures, extra injections are not required and the patient’s trust in the dentist is increased, which in turn reinforces the mentality of patient toward dental treatments and consequently promotes the oral health of the society.[1],[2],[3]

Injection pain induces fear of dental treatments. Vika et al.[4] found that scores of fear of injection in dental treatments were higher than those of medical treatments. Various studies have been conducted in dentistry to achieve higher success and to reduce injection pain, such as using topical anesthesia,[5],[6] increasing the injection time,[7] buffering or heating and cooling the anesthetic solution,[8] using vibration devices,[9] and cooling the injection site.[10] Moreover, the type of anesthetic solution affects the injection pain.[11]

Measures such as physical interventions employed on the injection site have been performed to reduce the injection pain.[12] Physical intervention employed on the injection site to reduce injection pain is based on gate control theory;[13] that is, stimulating thicker nervous fibers by any method such as cooling, warming, pressing, or vibrating the neural gate leads to reduced central perception of pain. However, it has been reported that pain reduction occurs due to non-noxious contact or vibration as a result of touch-induced inhibition at cerebral the cortex.[14]

In dentistry, this theory is used as a non-pharmacologic method. Stretching the mucosa,[15] using the coolant,[10] and vibrating the mucosa of injection site[9],[16],[17],[18],[19] are based on this theory. Massage therapy has always been used a technique to reduce muscular spasm,[20] to increase blood circulation[20 and to reduce swelling and edema.[21] Massage also exerts its effects on the concentration of circulation enzymes[22] and the nervous system.[21] Furthermore, massage causes the dilation of blood vessels through local axon reflex, which is in turn activated via release of histamine. Moreover, massage releases short-lived analgesics by activating and affecting the pain gates.[21]

Given the effect of oral injection site on the injection pain and the role of topical massage and its effect on nervous terminals and activation and release of neurotransmitters, and finding a simple and applicable solution to reduce infiltration injection pain in anterior maxilla, which has always been considered one of the most painful infiltration injection sites,[23] the present study was designed to assess the impact of topical massage before infiltration injection at anterior maxilla on the anesthesia success and pain reduction.

 Materials and Methods

Trial design, participants, sample size

A total of 30 individuals volunteered to participate in this double-blind, crossover trial [Figure 1]. Sample size was calculated to provide 90% power (α = 0.05) by PASS sample size software version 15.{Figure 1}

Inclusion and exclusion criteria

These criteria included lack of systemic disease, lack of allergy to Mepivacaine 3%, not using any anesthetic, analgesic, and anti-depression drugs during the past 2 weeks, having healthy anterior incisors without restoration and with positive response to vital signs, and absence of pain in 6 anterior incisors to percussion and palpation.[24]


The Massage was done intraorally at the vestibule depth as rotational movements by a finger for 1 minute. Then, a cartridge of Mepivacaine 3% (Septodont, PA, USA) was immediately injected into the vestibular depth of maxillary central incisor. The injections duration were 1 minute for all cases.

Allocation, randomization, blinding

The study was carried out as a crossover design, i.e., the right or left side of maxilla was selected and evaluated. Then 2 weeks later, the same location was evaluated by a different technique. Therefore, each person was his/her own control. Then the participants received injection with or without the “massage before the injection” were determined by random assignment.[6] The person who massaged the injection site differed from the ones who gave the injection and performed the assessment. Moreover, those who administered the injections were blind to the patients, sitting next to the unit, and immediately administered the injection after massage.

Outcome assessment

The injection pain score in both methods was measured immediately after the injection by Visual Analogue Scale (VAS).[25] The pain score was carried out at three times of needle insertion, 5 seconds after injection, and needle withdrawal by VAS:0: no pain1–3: little pain4–6: moderate pain7–10: severe pain

The success rate of anesthesia was recorded 5, 15, and 30 minutes after injection by a handheld style analog electric pulp tester − Gentle Pulse (Parkell, NY, USA).

Statistical analysis

Data were analyzed by SPSS 16 (IBM SPSS Statistics for Windows, Version 16.0. Armonk, NY: IBM Corp.) software using Friedman, Wilcoxon and McNamara tests.


A total of 30 participants, 16 males and 14 females, participated in this study. The mean scores of injection pain with and without the massage were reported to be 1.87 ± 1.6 and 2.2 ± 1.9, respectively. Further, the mean scores of pain 5 seconds after injection in groups with and without the massage were 4.28 ± 2.3 and 4.68 ± 2.5, respectively. Moreover, the mean scores of pain during needle withdrawal in groups with and without the massage were found to be 1.14 ± 1.5 and 1.81 ± 2.1, respectively. Despite the lower mean score of pain in the injection with the massage, these differences were not statistically significant (Wilcoxon, P > 0.05) [Table 1].{Table 1}

There was no significant difference for the success rate of anesthesia between injections at different intervals (Friedman, P > 0.05) [Table 2].{Table 2}

Moreover, the success of anesthesia in the injection with and without the massage at intervals 5 and 15 minutes after injection was not found to be significant (McNamara, P > 0.05). However, at the interval 30 minutes after the injection, 5 participants receiving the injection without the massage were anesthetized and when receiving the massage were not anesthetized, although no significant difference was found between them in terms of the success of anesthesia (McNamara, P > 0.05) [Table 3].{Table 3}


The results of this study showed that the massaging the injection site before the administration of anesthetic had no effect on the pain and the success of anesthesia.

The reduction of pain and anxiety is a basic principle that is followed by dentists. Anesthetic injection is an important part of dental procedures; however, the patient may experience pain during injection.[1],[2],[3] Injection pain can cause anxiety in patients, which is probably one of the causes of anesthetic failure.[26] Various studies have reported the role of massage in the reducing anxiety and pain in different areas of body.[27],[28] A systematic review have shown the positive impact of skin stroking in the reduction of vaccination injection pain.[12]

The massage can increase epinephrine level in the blood.[29] Therefore, in present study to prevent even the smallest possible confounding effect of anesthetic along with epinephrine, epinephrine-free Mepivacaine 3% was used.

Despite the inefficacy of injection pain in its success, clinicians should always consider a painless injection to reduce the patient’s anxiety. The success rate of the infiltration injection of central incisors peaked in the first 5 minutes, which is in line with the results of similar studies.[30]According to the gate control theory, pain gate can be alleviated by stimulating the nerves of injection site, which are responsible for signal transfer; the same effect is induced by massage, rubbering, pressure, ice pack, acupuncture, electric anesthesia, and vibration. Recently, a new tool has been made to reduce injection pain through vibratory stimulation, as a non-pharmacologic and harmless method. The results of using this tool with regard to the reduction of injection pain have been reported to be contradictory. Some studies have shown the positive effect of this tool,[16],[17] and have avoided pressure with the finger due to the lack of the complete monitoring of pressure level and frequency of the touch from person to person.[9] However, some studies, carried out based upon this theory, have indicated ineffectiveness of using vibratory devices in reducing injection pain.[18],[19]


Massage before injection had no impact on the pain of needle insertion and infiltration of anesthesia in the maxillary central incisors. Future studies are recommended to evaluate the effect of massage before dental injections on the anxiety of patients.


The authors would like to thank the volunteered participants of this trial.


The Regional Bioethics Committee affiliated to Kermanshah University of Medical Sciences approved the study protocol (#33150).


The full trial protocol can be accessed at the vice chancellery for research and technology, Kermanshah University of Medical Sciences, Kermanshah, Iran.

Financial support and sponsorship

This study has financially support by the vice chancellery for research and technology, Kermanshah University of Medical Sciences, Kermanshah, Iran (#33150).

Conflicts of interest

Khazaei S has editorial involvement with Dental Hypotheses.


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