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Apr 29, 2018 - Corresponding author. Tel.: +6285-665-82972; fax: +274-515-307. E-mail address: eltrin. khotimah. m@mail.ugm.ac.id (eltrin khotimah maharti) ...
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The 3rd International Conference of Integrated Intellectual Community Hanover, 28th - 29th April 2018

Smart Wet Injection Phantom Using Electrolyte Switch and Capacitive Sensor System for Dental Local Anesthesia Training Eltrin Khotimah Mahartia*, Archadian Nuryantic, Swastiana Eka Yunitaa, Adien Gumilangb, Muhammad Rifaldi Aldino Fahrezab, Lila Eva Silvanaa a Faculty of Dentistry, Universitas Gadjah Mada, Sleman, Indonesia Faculty of Engineering, Universitas Gadjah Mada, Sleman, Indonesia c Department of Dental Biomedical Science, Universitas Gadjah Mada, Sleman, Indonesia b

Abstract Student to student administration of dental local anesthesia training has possible risk to cause nerve and muscle trauma. This research aims to create the newest technology for dental local anesthesia training in mandibular region using electrolyte switch and capacitive sensor system. The device facilitates user to inject the fluid at the injection site, knows the accuracy of the dosage according to clinical standard operating procedure and knows the accuracy of the injection site, so the student can feel a real sensation in anesthetic training even without using human being as their subject. In this research, there were 3 methods, first was technique of prototype formation, second was sensor accuracy test and the last was data analysis. The result of this research was the creation of the newest technology of smart wet injection phantom with electrolyte switch and capacitive sensor system. Electrolyte switch could detect the accuracy of the injected fluid, using voltaic cell principle to make the switch-like system at each fluid level with electrode and electrolyte solution as the component of the switch. The capacitive sensor could detect accuracy of the injection site and placed in the injection area for inferior alveolar nerve, buccal nerve and lingual nerve. Accuracy of capacitive sensor and electrolyte switch system were above 80% and 90%, so it could be interpreted that the sensors had good accuracy. From this study, we conclude that the combination of electrolyte switch and capacitive sensor system can produce smart wet injection phantom which has good sensor accuracy so it can help dental student to practice local anesthesia in mandibular region accurately.

© 2018 ICONIC Keywords: Local anesthesia; nerve; capacitive sensor; electrolyte switch.

1. Introduction Local anesthesia is a treatment to eliminate the pain in certain areas, without causing loss of consciousness and work by inhibiting the conduction of pain in the peripheral nerves (Singh et al., 2017). Local anesthesia is one of the most important action for a dentist before doing an invasive treatment, such as tooth extraction and dental surgery (Lee et al., 2016). The mandibular anesthesia technique has a high failure rate because the

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Corresponding author. Tel.: +6285-665-82972; fax: +274-515-307. E-mail address: eltrin. khotimah. [email protected] (eltrin khotimah maharti)

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difficulty of achieving the precision of injection in inferior alveolar nerve block (Malamed, 2011). Therefore, the knowledge and anesthesia technique training for mandibular region is strongly emphasized for dental students. Three dental local anesthesia techniques of the mandibular region area are inferior alveolar nerve block technique that provide anesthesia for all teeth in the lower jaw, lingual block that provide anesthesia for tongue mucosal and the base of mouth. The buccal block that provide anesthesia for buccal gingiva (Suhael et al., 2016). In order to study these three techniques, preclinical student performed administration of dental local anesthesia with “student to student” system. The use of this training method give the advantage that the students can learn the actual injection technique in human so the anesthesia training is more effective. However, the use of this technique has low physical safety assurance and high risk for syncope, hematoma, and even paresthesia where in this case there is injury to the nerve that cause stiffening of the jaw area (Rosenberg et al., 2009). The trauma can occur because students are directly required to do their first injection in human, so the anxiety level and the risk for trauma are high (Chandrasekaran et al., 2014). Therefore, dental local anesthesia training needs a device that capable to substitute human for anesthesia practice at student’s first injection, without abandoning the principle of injection site and injection dose accuracy. The purpose of this study is to design and make wet injection phantom for dental local anesthesia training in mandibular region which combine capacitive sensor as detector of injection site accuracy and innovation of new system which is electrolyte switch system as detector of injection dose accuracy, as well as testing both sensor systems accuracy, so that the phantom can facilitate the dental student to feel a real sensation in anesthetic training at their first injection. 2. Material and Methods 2.1. Materials Microcontroller arduino uno (Geddes & Mark, 2016), household aluminium foil, aluminium wire, 3 mL syringe (Martinez et al., 2017), 10 MΩ resistor, salt, water, measuring tube, plastic pipe (3 mm in diameter), copper electrode, encoder SN74HC151-Q1 (Uzam, 2014), Rhodorsil-RTV 585 silicon rubber, brown, yellow, red dyes, acrylic board, LCD 1602 16x2 5V yellow screen, SMD light emitting diode. 2.2. Formation of the capacitive sensor Capacitive sensor operated based on capacitive concept and consists of a medium to high value resistor, a piece of wire and sensor plate (Du, 2015). This sensor was placed on the injection area for inferior alveolar nerve, buccal nerve and lingual nerve anesthesia. Capacitive sensor for buccal nerve injection site was made from sensor plate arranged from household aluminium foil which typically had 0.016 mm thickness. This aluminium foil was shaped into 0.5 cm by 1.5 cm in rectangular form. Inferior alveolar nerve and lingual nerve injection site were made from sensor plate arranged from aluminium wire mesh (See Fig 1). In addition, sensor plate was placed on the syringe handle. Capacitive sensor needs two Arduino pins to work, one as send pin and the other as receive pin. Receive pin was connected to the send pin via 10 MΩ resistor and sensor plate connected to the end of receive pin. The last step was programming the microcontroller using Arduino IDE 1.8.1 Version. Arduino Capacitive Sensing Library 04 version was used in this program. Capacitive sensor library changed the send pin and receive pin into a capacitive sensor, which could sense the electrical capacitance of the human body. When the syringe touched the sensor, it could form a capacitive circuit between the sensor with the human body through a syringe and a sensor plate on the syringe as shown in Fig 1. The circuit was sensed by the microprocessor and interpreted as an injection event. If the injection event was detected, the green LED could light up (success), and if otherwise the red LED could light up (not success).

Electronic copy available at: https://ssrn.com/abstract=3194467

Maharti et al. / Proceeding of the 3rd International Conference of Integrated Intellectual Community

(a)

(b) Fig. 1. (a) capacitive sensor design; (b) sensor plate on the syringe

2.3. Formation of the electrolyte switch system Electrolyte switch was an innovative switching system using electrodes and electrolyte solutions (2 grams of salt in 50 mL water) to connect a circuit, with the principle of voltaic cells. The sensor consisted of measuring tube, copper electrode, and multiplexer. Measuring tube was used to put the electrode and the injected liquid. The measuring tube was made by using a 5 mL tube. In this study, anesthetic volume accuration was analogous as anesthetic dose accuration in accordance with standard operating procedure commonly applied in Indonesia, 0.5 mL for lingual nerve and 1 mL for inferior alveolar nerve. The copper electrodes were inserted through 9 tube holes and wired to encoder (MUX) SN74HC151-Q1 8 to 1 multiplexer IC with the aim to simplify the sensor output, produced one output pin and three selector pins that went into the microcontroller as shown in Fig 2. The last step was programming microcontroller using Arduino IDE 1.8.1 Version. Microcontroller was used to pull the electrode voltage up to 5 volts and monitoring the voltage change. When the tube was filled with the liquid, volume detection electrode could be connected to the ground electrode through the liquid, causing the voltage to drop. Microcontroller monitored which electrode had ‘voltage drop’ and interpreted it into volume measurement. 2.4. Formation of the external structure of the phantom head and phantom box Internal structure of the phantom head was arranged from the acrylic skull and sensor attached in mandible, while the exteral anatomy structure of phantom was formed with silicon rubber (Rhodorsil-RTV 585) and brown, yellow, red dyes. Phantom box was arranged from acrylic board which has been designed before, to put all electrical and mechanical components of phantom as shown in Fig 2 .

(a)

(b) Fig. 2. (a) electrolyte switch system design; (b) phantom box design

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2.5. Sensor accuracy test Capacitive sensor accuracy test was performed by injected the needle into local anesthesia sites in mandibular region for 30 times/each site and with the same operator for consistently injection. The success of sensor to detect the injection was known from the difference in ‘time of pause’ of the voltage charging by the microcontroller due to the presence of human hands and syringe that touch the sensor plate. If the ‘pause time’ was small and didn’t pass through the threshold then it was interpreted ‘no injection process’ or detection failed (I0 = 0), and if otherwise detection was success (I1= 1). The total accuracy of the sensor was described by equation 1. Electrolyte switch accuracy test was done 30 times for each region (left sensor and right sensor) by pouring 1 mL and 0.5 mL of electrolyte liquid into the measuring tube followed by seeing the result at LCD monitor and compared it with the actual volume of the liquid. If the sensor could detect accurately, then on 1 mL of injected liquid there would be 8 strips on the monitor, these 8 strips were interpreted with 100% success at one injection process in right or left sensor (%IR/L = percentage of success for right/left sensor). The total percentage of success was measured with equation 2. In this study, the accuracy was determined based on the proximity percentage of success with 100%, more close with 100% the sensor was declared more accurate. I1a + I1b + I1c +……I1x Pc =

X 100%

(1)

30 {(%IL1 + % IL2 +……%IL15) ÷ 15} + {(%IR1 + % IR2+……%IR15) ÷ 15} Ps =

(2) 2

3. Results and Discussion 3.1. Smart wet injection phantom system and mechanism Smart wet injection phantom was an educational device that was able to describe most of the anatomical structure of human mouth and the anesthesia process, but this device was not enough to replace the overall human role as subject in anesthesia training. So, this tool was very useful in overcoming fear and as the training device for the dental students at their first injection before heading human to minimize the stress, anxiety, risk of trauma and also to improve the skill. The mechanism of this tool was capacitive sensor would detect the accuracy of injection site showed by the green or red LED. Electrolyte fluid as an anesthetic liquid was injected and flowed through the cavity in phantom mucosa to the plastic pipe and finally reached measuring tube in electrolyte switch system (See Fig 3). If the volume of electrolyte liquid was injected precisely, the microcontroller connected to electrolyte switch system gave this information to LCD and student could know the output. The first output was information about injection dose accuration indicated by success or not success, the second output was information about body area that was successfully anesthetized for example the anesthesia of inferior alveolar nerve gave information ‘all teeth in right/left region of mandible’. Anesthesia detection for buccal nerve only used capacitive sensor because the position, the thickness of buccal mucosa and the technique that was relatively simple. The student can know the injection site accuration but could not inject electrolyte liquid in the area. When the injection of buccal nerve was right, LED turned green and the LCD gave information about the anesthetized body namely ‘buccal gingiva’.

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Fig. 3. components of smart wet injection phantom

3.2. Electrolyte switch and capacitive sensor accuracy Capacitive sensor accuracy test was shown in Table 1. Capacitive sensor system accuracy test for inferior alveolar nerve, lingual nerve, and buccal nerve generated values above 80% for all injection sites. So with a value close to 100%, the capacitive sensor system applied to phantom proved able to detect the accuracy of the injection site well. This study also measured the accuracy of electrolyte switch sensor, the result was shown in Table 2 and Fig 4. The test results and sensor accuracy analysis on the electrolyte switch system showed an accuracy value above 90%, so the electrolyte switch system also proved able to measure the accuracy of electrolyte fluid volume in samples with a volume of 0.5 mL and 1 mL very well. Table 1. Capacitive sensor total accuracy Inferior alveolar nerve injection site (%)

Lingual nerve injection site (%)

Buccal nerve injection site (%)

90.0

93.3

86.7

Table 2. Electrolyte switch sensor accuracy Type of test

Right sensor (SD)

Left sensor (SD)

Percentage of success / mean

25% Percentil

95 % Percentil

Sensor accuracy at 0.5 mL test volume (%)

96.7

95.0

95.85

100

100

(10.3)

(12.9)

Sensor accuracy at 1 mL test volume (%)

95.8

100

97.9

100

100

(6.1)

(0.0)

Electrolyte Switch Sensor Accuracy (+/- SD) sensor accuracy (%)

Sensor Accuracy

Capacitive Sensor Accuracy (%)

95% 90% 85% 80% Inferior Nerve

Lingual Nerve

Buccal Nerve

105 100 95 90 85 80

right left 0.5 ml

1 ml Test Volume

(a)

Nerve Site

(b)

Fig. 4. (a) capacitive sensor accuracy; (b) electrolyte switch sensor accuracy

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4. Conclusion Student to student dental local anesthesia training has low physical safety assurance, therefore it needs a device that capable to substitute human for anesthesia practice mainly in mandibular region. Smart wet injection phantom is one of the solution. Capacitive sensor and electrolyte switch system were two main systems to make the phantom. Capacitive sensor was made to detect the injection site accuracy and operated based on capacitive concept. It consisted of a medium to high value resistor, a piece of wire and sensor plate. Electrolyte switch was an innovative switching system made from electrodes and electrolyte solutions with the principle of voltaic cells, it could detect the accuracy of the injection dose. The sensors were connected to microcontroller and programmed using arduino IDE 1.8.1 and the output was showed by LED dan LCD. Capacitive sensor and electrolyte switch accuracy test was performed and accuracy of capacitive sensor and electrolyte switch system from the test were above 80% and 90%. The combination of electrolyte switch and capacitive sensor system can produce smart wet injection phantom which has good sensor accuracy and can help the dental student to practice local anesthesia in mandibular region.

Acknowledgements The authors are indebted to the financial support from DAMAS Project 2017 held by Faculty of Dentistry, Universitas Gadjah Mada.

References Chandrasekaran, B., Cugati, N., Kumaresan, R., 2014. Dental Students’ Perception and Anxiety Levels during their First Local Anesthetic Injection, Malays J Med Sci 21, p. 45–51. Du, W., 2015. Resistive Capacitive Inductive and Magnetic Sensor Technologies. CRC Press, New York, p. 99. Geddes, Mark, 2016. Arduino Uno Project Book. No Starch Press, San Fransisco, p. 3. Lee, J., Kim, H., Seo, K., 2016. Dental Anesthesia For Patients with Allergic Reactions to Lidocaine : Two Case Reports, J Dent Anesth Pain Med 16, p. 209-212. Malamed, S.F., 2011. Is the mandibular nerve block passé ?, J Am Dent Assoc 142. Martinez, S. L., Werner-McCullough, M., 2017. Calculating Drug Dosages, A Patient-Safe Approach to Nursing and Math. F.A. Davis Company, Philadelphia, p. 181. Rosenberg, M., Orr, D., Starley, E., Jensen, D., 2009. Student-to-Student Local Anesthesia Injections in Dental Education: Moral, Ethical, and Legal Issues, J Dent Educ 73, p. 127–32. Singh, R., Surendra, S., 2017. Techniques of Local Anaesthesia, IOSR J Dent Med Sci 16, p. 84–90. Suhael, A., Nafeesa, T., Omar, A., 2016. Single Injection Straight Line Approach to Anesthetize Inferior Alveolar Nerve, Long Buccal Nerve and Lingual Nerve : A New Technique, OHDM 15, p. 127-130. Uzam, M., 2014. Building Programmable Logic Controller with a PIC 16F648A Microcontroller. CRC Press, London, p. 1.