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International Journal of Clinical Pediatric Dentistry logoLink to International Journal of Clinical Pediatric Dentistry
. 2026 Feb 12;19(2):164–170. doi: 10.5005/jp-journals-10005-3396

Comparative Evaluation of Buzzy System and Conventional Masked with Camouflage Syringe for Pain Perception in 5–12-year-old Children: A Split-mouth Study

Anuja Anant Dhembare-Patil 1,✉, Mansi Jain 2, H P Suma Sogi 3, Priyanka Sharma 4, Apurva Gambhir 5, Shambhavi Kumari 6
PMCID: PMC12960342  PMID: 41800015

Abstract

Background

In pediatric dental treatment, administration of local anesthesia (LA) is a fearful condition that leads to “escape alert” in children. This escaping treatment excuse, unfortunately, ends up worsening the overall oral health of the child. Hence, it is crucial to cultivate child-friendly methods to reduce pain during injection.

Aim

To assess which system, the Buzzy system or the conventional masked with camouflage syringe, aids in a greater reduction of pain perception in patients during LA procedures.

Method

A randomized controlled trial was conducted on 34 subjects aged between 5 and 12 years who required LA administration. Subjects were recruited by lottery method into group I—conventional masked with camouflage technique (control), group II—precooling along with vibration using the Buzzy system (experimental).

Results

In the present study, the pain score using the Buzzy system was statistically lower compared to the experimental group (p = 0.0001).

Conclusion

The Buzzy system is a compatible and economical method to diminish dental pain perception during LA administration.

How to cite this article

Dhembare-Patil AA, Jain M, Sogi HP S, et al. Comparative Evaluation of Buzzy System and Conventional Masked with Camouflage Syringe for Pain Perception in 5–12-year-old Children: A Split-mouth Study. Int J Clin Pediatr Dent 2026;19(2):164–170.

Keywords: Buzzy system, Conventional masked with camouflage, Local anesthesia, Pain perception

Introduction

Pain in dentistry is not just accounted as a warning indicator; it is considered an evil that must be conquered. Dental anxiety is a condition in which one expects pain during dental procedures and feels as though they are losing control of the situation.1

Fear is a crucial state that influences one's thinking and behavior. Fear of the unknown triggers the “Fight or Flight” response to protect oneself from threatening situations.2 Dental fear, the emotional reaction toward certain atrocious stimuli or dental phobia, a variant of anxiety which can be characterized based on a persistent reaction to a clearly noticeable situation, leads to an increased pain anticipation, is considered a demanding outlook of management, and is also a hurdle to efficient treatment.3,4 Children and adolescents are exposed to needles by medical personnel during standard medical procedures, such as vaccinations, and they are more likely to develop needle phobia.5,6

Fear of injections is a well-documented significant challenge in managing the psychological and emotional responses, often leading to anxiety and avoidance of dental care.7 The camouflagesyringe mitigates these issues by masking the visual appearance of the traditional dental syringe with something more familiar or engaging, such as a playful design or a toy-like appearance (Fig. 1).

Fig. 1:

Fig. 1:

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Camouflage syringe sleeve with conventional syringe

The use of novel tools to improve treatment results and patient experiences is booming in pediatric dentistry's everyday practice. One such device is the “Buzzy system,” which is a noninvasive, hand-held, portable tool crafted to reduce discomfort throughout dental treatments (Fig. 2).8

Fig. 2:

Fig. 2:

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Buzzy system

Therefore, the purpose of this study was to clinically assess the efficacy of a conventional mask with a camouflage syringe and the Buzzy system in reducing pain perception in children aged 5–12.

Materials and Methods

Randomized split-mouth technique was carried out in the Department of Pediatric and Preventive Dentistry in MMCDSR, Mullana, Ambala, Haryana, on 34 healthy children aged 5–12 years having Frankle's definitively positive, positive, and negative behavior who required local anesthesia (LA) for any kind of dental treatment. Patients with a known history of allergy to lidocaine and restricted mouth opening were excluded from the study. The study was carried out according to the Declaration of Helsinki (2013) after getting institutional ethical clearance and informed consent from the parents.

Subjects were assigned to the conventional mask with a camouflage syringe and Buzzy system by the lottery method. Pain perception was evaluated using Wong–Baker's face pain rating scale, and heart rate and SpO2 were recorded using a pulse oximeter.

Clinical Procedure

Subjects were made to sit comfortably on the dental chair and were explained about the administration of LA and the pain rating scale. SpO2 and heart rate were recorded with a pulse oximeter. A color-printed model of the Wong–Baker faces pain rating scale was handed to the subjects, and they were instructed to rate the anticipated pain of the injection.

Conventional Masked with Camouflage Syringe Technique

Local anesthesia was administered by the conventional technique, which was masked with Angelus Angie Crocodile sleeve preadjusted according to the conventional syringe. After the administration of anesthesia, the subjects were asked to rate the actual pain experienced on Wong–Baker faces pain rating scale by selecting the face that closely represented the pain intensity, and the postoperative pulse oximeter readings were recorded (Fig. 3).

Fig. 3:

Fig. 3:

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Conventional masked with camouflage syringe LA administration

Buzzy Technique

The subjects were acquainted with the Buzzy system, which consists of a Vibrator part and cooling wings. Subjects were explained about the vibration and tingling sensation that would be experienced during the administration of LA, along with the cooling effect at the site. Buzzy vibrator, along with the precooled wings, was placed on the extraoral site for a minute before the procedure, and the LA administration was completed with the Buzzy system being in place. Postoperatively, the subjects were asked to rate the actual pain perceived on Wong–Baker faces pain rating scale, and pulse oximeter readings were also recorded (Fig. 4).

Fig. 4:

Fig. 4:

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Administration of LA with the Buzzy system

Statistical Analysis

The data were coded and entered into a Microsoft Excel spreadsheet. Analysis was done using SPSS version 20 Windows software program. Descriptive statistics included computation of percentages, means, and standard deviations (SDs). It was a randomized split-mouth study design carried out in 34 subjects. Statistical analysis was done using the signed rank test with continuity correction, paired t-test in intragroup, whereas the Wilcoxon rank sum test with continuity correction was carried out in intergroup comparison (Fig. 5).

Fig. 5:

Fig. 5:

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Schematic study design

Results

SpO2 Levels Evaluation

The SpO2 level was considered for the health status of the child, which suggested the subjects were healthy.

Observed p-value (.4154) shows there is no significant difference in the distribution of SpO2 differences (pre- vs postintervention) between the camouflage and Buzzy groups (Tables 1 and 2).

Table 1:

SpO2 evaluation of camouflage group

SpO 2 —pregroup SpO 2 —postgroup
Frequency count 34 34
Mean 97.56 98.09
SD 1.19 0.79
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Table 2:

SpO2 evaluation of the Buzzy group

SpO 2 —pregroup SpO 2 —postgroup
Frequency count 34 34
Mean 97.82 98.03
SD 1.11 0.9
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Heart Rate Evaluation

The mean heart rate under the camouflage group increased slightly from 94.59 ± 5.73 to 94.82 ± 4.69 after the intervention, whereas it decreased significantly from 95.06 ± 5.28 to 93.24 ± 5.59 with a p-value of 0.01238 in the Buzzy group.

On intergroup comparison, though, there was no statistically significant difference in the distribution of heart rate differences (pre- vs postintervention) between the camouflage and Buzzy groups (p = 0.1333) (Tables 3 and 4).

Table 3:

Heart rate evaluation of camouflage group

Heart rate—pregroup Heart rate—postgroup
Frequency count 34 34
Mean 94.59 94.82
SD 5.73 4.69
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Table 4:

Heart rate evaluation of the Buzzy group

Heart rate—pregroup Heart rate—postgroup
Frequency count 34 34
Mean 95.06 93.24
SD 5.28 5.59
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Pain Scale Evaluation

On analyzing the data in the camouflage group, the median pain score decreased from 6 (preintervention) to 4 (postintervention) with a decrease in the interquartile range (IQR) from 4 to 2, and the p-value being 0.01594. This suggests that there was an overall reduction in pain with levels being more uniform across participants postintervention.

The median pain score in the Buzzy group decreased from 6 (preintervention) to 4 (postintervention), though the IQR remained 4 with a p-value of 0.0001328, thus displaying a positive impact on pain reduction.

Intergroup comparison concludes a significant difference in the distribution of the pain scale between the camouflage and Buzzy groups, the Buzzy group displaying a statistically significant reduction with p-value (.003083), suggesting it to be significantly effective in reducing pain (Tables 5 and 6).

Table 5:

Pain scale evaluation of camouflage group

Pain scale—pregroup Pain scale—postgroup
Frequency count 34 34
Median 6 4
IQR 4 2
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Table 6:

Pain scale evaluation of the Buzzy group

Pain scale—pregroup Pain scale—postgroup
Frequency count 34 34
Median 6 4
IQR 4 4
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Discussion

Dental anxiety and phobia emerging during childhood lead to avoiding dental care, which exacerbates oral health issues linked to a lower quality of life.9 The main cause of dental fear, mainly in children and teenagers, is local anesthetic injections because they are usually linked to pain and discomfort. The dread of needles is frequently justified as an excuse for missing dental appointments.10

Pain should be assessed and treated as soon as possible since it is an inherently complex, unpleasant sensory and subjective experience. Children's perception of pain depends on the interplay of environmental, behavioral, developmental, physiological, and psychological elements. In order to lessen children's suffering, pediatric dentists are responsible for removing and calming the pain.11

Throughout its history, humanity has worked to manage the suffering brought on by illness and tragedy. Evidence dating back more than 4500 years showed that Egyptians employed techniques to compress peripheral nerves in order to alleviate pain.12 Homer's Iliad, written in 762 BC (before Christ), describes the use of herbal treatments for pain management in his song about the Trojan War. Until the first framework for hypodermic syringes appeared in America in the early 1800s, these methods in their various forms constituted the primary arsenal of local pain management. Others had early discussed the use of electricity produced by the torpedo ray, as well as cold water along with ice for pain reduction.12

Local anesthesia is the most effective way to manage pain in dental treatments. Managing needle phobia is the largest obstacle for children.13 Kumar et al.14 found that the most common reason for children to avoid dental treatment was pain from injections, with a high prevalence rate (p = 0.256).14

Children's coping mechanisms can be improved through behavioral management, which is both an art and a skill.10 It is a succinct, constantly changing technique for building a forgiving, trustworthy relationship between the patient and the physician. Children's intellectual, emotional, and social development differs, and their social and familial environments influence their temperaments and views.11

Different techniques were implemented to diminish the pain during the anesthetic injection procedure.15 The surface area of the needle insertion is numbed via topical anesthesia. Infiltration pain can be reduced by buffering acidic local anesthetics with sterile sodium bicarbonate.16 Injection pain is reduced by warming local anesthetics near core body temperature.17 According to a meta-analysis by Hogan et al.,18 warming local anesthetics on average decreased discomfort by 11 mm on a 100 mm scale. According to anecdotal evidence, some physicians warm injections in their hands before giving them.19

Cryoanesthesia precooling of the injection site reduces pain perception during local anesthetic administration by producing an immediate cooling effect and evaporating more quickly from the mucosal membrane. Finer needles can decrease pain and offer benefits that can improve patient compliance, according to Gill and Prausnitz.20 However, Webb21 noted that finer needles were not appropriate for nerve blocks because of the possibility of breaking. Farsakian and Weine22 supported the idea that the sharpness of the bevel, not the gauge, is crucial in pain avoidance. Fuller et al.,23 Mollen et al.,24 and Brownbill et al.25 came to the conclusion that the “degree of pain was not related to needle gauge size.”

In the last few years, computerized syringes such as WAND/compuDent for single-tooth anesthesia have been introduced; based on the computer program, it controls anesthetic flow, providing low-pressure injections that result in pain-free and precise anesthetic delivery. Techniques such as Oraqix, a needle-free method for subgingival anesthesia, and 1991 jet injections (Syrijet and Med-Jet), which are based on the principle of using mechanical energy to create a pressure sufficient to push a dose of liquid medication through a very small orifice, have been proven effective.26 Electronic dental anesthesia uses electric current to stimulate nerves for pain relief; there is no unpleasant residual anesthetic effect.26

In order to meet the needs of each patient, clinicians today employ a variety of techniques. More recently, newer distraction techniques for administering LA have been developed, such as the use of needleless jet syringes, intraoral lignocaine patches, vibro-tactile devices, computer-controlled local anesthetic delivery systems, safety dental syringes, and devices for intraosseous anesthesia.27 Active techniques involve the patient directly participating in treatment through the use of toys, controlled breathing, guided imagery, and cognitive behavioral therapy; passive techniques involve relaxation and stimulus observation with auditory and/or audio–visual content.28

It is widely recognized that children's perceptions of medical instruments, particularly needles, are often influenced by their appearance, which evokes fear and anxiety due to their association with pain and medical procedures.29 Keeping the dental syringe that might be scary, out of the child's sight is considered a critical factor in minimizing anxiety and fostering trust with child patients.30 Camouflaging the dental syringe to hide the threatening metal needle during LA administration can be an effective distraction tool to alleviate dental anxiety; therefore, an advanced autoclavable, colorful, and playful alligator-shaped syringe sleeve to cover and camouflage the needle31 and thereby eliminating the visual input of the metal syringe and needle is reliable.32 The core principle behind the camouflage syringe is rooted in psychological concepts of behavioral distraction and cognitive restructuring.33

The various features of the camouflage syringe to modify the appearance of the standard dental syringe by incorporating elements that make it look less clinical and more child-friendly can be8

  • Colorful covers or sleeves: Which feature bright colors or patterns, transforming the syringe into an object that is visually engaging and less threatening.

  • Cartoon characters or animal motifs of familiar characters, animals, or even whimsical designs that appeal to children's imagination and sense of play.

  • Ergonomically designed grips with soft, rounded, or contoured grips to make the device easier to handle, adding to its nonthreatening appearance.

These modifications address the child's perception of the instrument rather than the actual sensory experience of the injection itself.8

Use of an extraoral cold patch and a vibrating device called Buzzy Bee™ (Pain Care Labs, United States) consisting of a vibrating motor encompassing a bee-shaped body and awing-shaped detachable ice pack34 are two examples of the various pharmacological, physical, and psychological distraction interventions that have been proposed to reduce pain from needle prick, during deposition of the solution into the tissue, and after removal of the needle.35 Buzzy Bee's efficacy is based on the gate control theory provided by Melzack and Wall in 1965 and the distraction principle.36

Gate control theory accords a modulating center in the dorsal horn of the spinal cord, which serves as a pathway for pain signals that transmit from the peripheral nervous system to the central nervous system.37 Pain perception can be altered by activating nerve fibers that transmit non-noxious stimuli. Melzack and Wall37 state that tiny neural networks distributed along the dorsal horn of the spinal cord are responsible for relieving the pain in a specific body location when an intense tactile stimulation is applied at the same place. Myelinated A-beta type nerve fibers send vibration stimuli at a speed of 30–70 m/s, while unmyelinated A-delta and C-type nerve fibers convey pain at a speed of 6–30 and 0.5–2 m/s, respectively.38 Nerve impulses evoked by tactile sensation are transmitted through A-beta tactile fibers, which in turn depress pain transmission through “A” delta and “C” nociceptive fibers at the secondary neuronal cell bodies in the dorsal horn. Hence, vibration when applied as a counter-stimulation to an anesthetic injection site reaches the brain before the pain sensation does.39 These neurons are found in the substantia gelatinosa in the dorsal horn of the spinal cord, where inhibitory interneurons block nociceptive impulses en route to the brain. Axons of first-order nociceptors are low-threshold afferent mechanoreceptors. Mechanoreceptors generate high-rate action potentials because they are low.

Another crucial element of Buzzy's effectiveness is distraction; by offering a sensory experience that rivals the dental procedure, the device helps divert the patient's focus from the procedure and towards the cooling and vibrating sensations. By lowering the psychological stress related to the procedure, Buzzy contributes to the creation of a calmer and cooperative environment.36

Thus, the Buzzy system is associated with three different components for pain modulation:

  1. Distraction: Distracting the child with a toy-like device.

  2. Vibration: An extraoral application of a bee-shaped device at the site of LA administration produces a mechanical action.

  3. Cryotherapy effect: By a detachable precooled wing of the bee-shaped gadget as a base.40

Using vibrating devices and extraoral cold significantly reduces pain perception in pediatric patients during local anesthetic deposition. Vibration stimulates primary endings of the muscle spindle, Pacinian corpuscles, and mechanoreceptors, such as Meissner's corpuscles in the skin, subcutaneous tissues, and bony structures.37

Heart rate is regarded as a reliable and sensitive objective metric for evaluating children's anxiety throughout various dental treatments since it is a clear sign of stress levels.41

At baseline, before LA administration and after LA administration was finished, patients' heart rates were measured using a pulse oximeter and reported as beats per minute (bpm) and SpO2.

The Wong–Baker scale, which is regarded as valid and reliable in the 3–18 age group, uses six different facial expressions to illustrate a spectrum of pain intensity from a score of 0–10, where a score of 0 indicates no pain and a score of 10 indicates the highest conceivable pain. Facial expression drawings, also known as “face scales,” are a popular method of assessing pain severity in pediatric populations.31

SpO2 Levels Evaluation

The SpO2 level was taken into account while assessing the child's health, indicating that the individuals were in good health.

The observed p-value (.4154) indicates that the distribution of pre- vs postintervention SpO2 differences between the Buzzy and camouflage groups does not differ significantly.

Heart Rate Evaluation

After the intervention, the mean heart rate in the Buzzy group dropped significantly from 95.06 ± 5.28 to 93.24 ± 5.59, with a p-value of 0.01238, whereas it increased slightly in the camouflage group from 94.59 ± 5.73 to 94.82 ± 4.69.

However, when comparing the camouflage and Buzzy groups, there was no statistically significant difference in the distribution of heart rate differences (pre vs postintervention) (p = 0.1333).

Hence, a decrease in postheart rate values in the Buzzy group signifies reduced anxiety, thus enriching the effectiveness of this child-friendly device, which distracts the child and increases co-operation during LA administration.

Similar observations were reported by Tatiya et al.,42 where pulse rate decreased significantly postoperatively during administration of LA in a customized mucosal vibrator as compared to topical anesthetic gel (p = 0.0001).42

Narimany et al.43 reported that neither the Buzzy nor the traditional control group's mean difference in heart rates before and during injection decreased considerably.43

Similar to our observations, Shetty et al.36 also noted that, following the procedure, the Buzzy group's heart rate decreased statistically significantly (p < 0.05) in comparison to the control intervention.36

Research by Jain et al.44 and Suohu et al.45 observed and found no statistically significant difference in heart rate between the Buzzy and control groups.

The conventional group and the camouflage group did not exhibit statistically significant changes in heart rate (p = 0.788), according to Bagher et al.31

Pain Scale Evaluation

In the statistical analysis, the median is used in place of the mean for the pain scale analysis, since the pain scale is a scaled value and not numerical values. Similarly, the IQR in place of SD is used, due to the nature of the Pain scale data.

On analyzing the data in the camouflage group, the median pain score decreased from 6 (preintervention) to 4 (postintervention) with a decrease in the IQR from 4 to 2, and the p-value being 0.01594. This suggests that there was an overall reduction in pain with levels being more uniform across participants postintervention.

The median pain score in the Buzzy group decreased from 6 (preintervention) to 4 (postintervention), though the IQR remained 4, with a p-value of 0.0001328, thus displaying a positive impact on pain reduction.

Intergroup comparison reveals a substantial difference in the distribution of the pain scale. The Buzzy group shows a statistically significant reduction with a p-value of 0.003083, indicating that it is significantly beneficial in reducing pain.

Cryotherapy, vibration, and distraction are components of multimodal approaches used in Buzzy systems. These approaches were explained by the gate control theory and expanding neuroscience research, which shows that different divisions in the anterior cingulate and prefrontal cortices play a supporting role in hypnotic responding.34

In this study, we took into account the patient's perception of pain during the deposition of the local anesthetic solution into the tissue, which may be caused by the tissues' expansion, the Buzzy Bee device's adjustment of the pH of the solution, or the activation of both A-delta and C fibers. Consequently, the Buzzy system has proven to be effective in reducing the child's pain during the administration of LA.34

According to a study by Narimany et al.,43 Buzzy considerably lessens the impression of pain in pediatric patients receiving local anesthetic deposition when compared to traditional methods.43

The impact of camouflage syringes and child-friendly dentist gear was assessed by Ahmad et al.,46 children preferred the camouflage syringe (mean score: 8.5, SD: 1.3) over the dentist attire (mean score: 3.4, SD: 1.6) (p < 0.001).46

Bagher et al.31 stated that the camouflaged group's FLACC scores and Vietnam's anxiety rating scale were considerably lower than those of the traditional group. Hence, recommending the usage of a camouflage syringe in the daily routine.31

In children who needed extraction and pulpectomy, Sahithi et al.47 found that external vibration with a Buzzy device was significantly more effective (p = 0.05) than counter stimulation at reducing needle-associated discomfort.47

A systematic review and meta-analysis of 1,659 articles retrieved from the Scopus, Cochrane, and PubMed databases, Faghihian et al.48 found that Buzzy showed promising results in reducing pain perception, while the dental vibe was ineffective in reducing pain perception for pediatric dental injections.48

Conversely, Semerci et al.49 assessed the effectiveness of Buzzy and cold spray in reducing pain in children aged 5–12 years. The Buzzy group's pain scores were higher than the cold spray group's (p < 0.001), while the mean scores for anxiety and fear were similar (p > 0.05). The cold spray was more effective than Buzzy at reducing pain.49

Thus, the current study's findings indicated that the Buzzy device can be used as an adjunct in routine dental procedures when giving children LA. The child-friendly toy with easy implication enhances the child's co-operation, its vibratory action distracts the child, and cryotherapy, in turn, helps in effectively reducing the anxiety and pain.

Conclusion

Promising results were achieved concerning the use of the Buzzy device. The user instructions for Buzzy stipulate that vibration has the power to bring down discomfort level if the patient markedly fears undertaking an injection, and also mention that the hum of the vibratory portion seemed to have a calming effect, along with the cooling sensations brought by the precooled Buzzy wings. This Buzzy system was effective in reducing perceived dental pain, and dentists can use this simple, playful device to cheer up patients and reduce anxiety.

Orcid

Priyanka Sharma https://orcid.org/0000-0003-3746-8099

Footnotes

Source of support: Nil

Conflict of interest: None

References

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