Artigo anestesia local computadorizada (1)

Prévia do material em texto

118 | wileyonlinelibrary.com/journal/ipd Int J Paediatr Dent. 2020;30:118–135.© 2019 BSPD, IAPD and John Wiley & Sons A/S. 
Published by John Wiley & Sons Ltd
1 | INTRODUCTION
Anxiety and fear may act as a barrier for dental treatment,1 
especially when local anaesthesia is involved.2 These feel-
ings probably have originated from experiences of pain 
during previous dental treatments, which demonstrate the 
importance of pain control during paediatric dental treat-
ment.3 Local anaesthesia is the most common method to do 
so, but it is also one of the factors that can trigger fear and 
anxiety, leading to difficulties for behaviour management 
in paediatric patients.4 Considering that severe anxiety and 
fear may enhance pain perception,1 it is fundamental to ex-
plore approaches that have potential to reduce the pain and 
discomfort associated with local anaesthesia.5 Currently, the 
use of topical anaesthesia, prolonged injection time,6 vibro-
tactile devices, and jet injectors7are the available tools for 
this purpose.
Considering that the pain during anaesthesia is caused by 
the stimulus to the sensors of pressure, pain, and temperature, 
Received: 19 July 2019 | Revised: 6 September 2019 | Accepted: 30 September 2019
DOI: 10.1111/ipd.12580 
R E V I E W
Does computerized anaesthesia reduce pain during local 
anaesthesia in paediatric patients for dental treatment? A 
systematic review and meta‐analysis
Priscila de Camargo Smolarek1 | Letícia M. Wambier2 | Leonardo Siqueira Silva1 | 
Ana Cláudia Rodrigues Chibinski1
1State University of Ponta Grossa, Paraná, 
Brazil
2Positivo University, Curitiba, Brazil
Correspondence
Ana Cláudia Rodrigues Chibinski, State 
University of Ponta Grossa, Dental Post‐
Graduate Program, Rua Carlos Cavalcanti, 
4748, Bloco M ‐ Uvaranas, Ponta Grossa, 
Paraná – Brazil.
Email: anachibinski@hotmail.com
Abstract
This systematic review and meta‐analysis analysed whether pain and disruptive 
behaviour can be decreased by the use of computerized local dental anaesthesia 
(CDLA) in children. The literature was screened to select randomized clinical tri-
als that compared computerized and conventional anaesthesia. The primary outcome 
was pain perception during anaesthesia; the secondary, disruptive behaviour. The 
risk of bias of individual papers and the quality of the evidence were evaluated. 
After search, 8389 records were found and 20 studies remained for the qualitative 
and quantitative syntheses. High heterogeneity was detected for both outcomes. For 
the pain perception, the overall analysis showed a standard mean difference of −0.78 
(−1.31, −0.25) favouring CDLA; however, when only studies at low risk of bias 
were analysed (subgroup analysis), there was no difference between the two tech-
niques [−0.12(−0.46, 0.22)]. For disruptive behaviour, no differences were detected 
for continuous [−0.26 (−0.68, 0.16)] or dichotomous data [0.81 (0.62, 1.06)]. The 
quality of evidence was judged as low for pain perception and very low for disruptive 
behaviour. It is concluded that there is no difference in the pain perception and dis-
ruptive behaviour in children subjected to computerized or conventional dental local 
anaesthesia. Notwithstanding, the quality of the available evidence is low.
K E Y W O R D S
anaesthesia, child, dental, meta‐analysis, pain, systematic review
https://orcid.org/0000-0001-7845-0261
https://orcid.org/0000-0002-9696-0406
mailto:
https://orcid.org/0000-0001-7072-9444
mailto:anachibinski@hotmail.com
 | 119SMOLAREK Et AL.
controlling the pressure that the anaesthetic solution exerts 
on the tissues when injected, as well as the speed of injec-
tion is one approach that has good potential to reduce the pain 
during anaesthesia.8 Based on this finding, the computer‐con-
trolled local anaesthetic delivery (CCLAD) was developed. 
The central technology of this system is a constant and slow 
delivery rate of the local anaesthetic solution with pressure 
control, at a rate below the pain threshold, since the flow rate 
of the local anaesthetic is controlled by a computer‐controlled 
pump.5 This device allows that, regardless of the variations in 
tissue resistance, a potentially painless injection can be done.3 
This can be challenging to accomplish with the conventional 
anaesthesia 6 since manual injection is subjected to individual 
variations regarding the pressure and volume of the anaes-
thetic solution that is being injected.9 The control of velocity 
and pressure during the anaesthetic solution injection is one 
possible reason that could stimulate a paediatric dentist to in-
corporate a CCLAD device in his/her daily practice.
Different CCLAD have been developed, such as The 
Wand® (subsequent versions named as Wand Plus® and 
CompuDent®) (Milestone Scientific,Livingston, New Jersey, 
USA), Quicksleeper™ (Dental HiTec, Cholet, France), 
Sleeper One™ (Dental Hi Tec, Cholet, France), and Comfort 
Control Syringe™ (Dentsply International, York, PA, USA)7 
and numerous papers comparing the conventional technique 
with the computerized technique have been published.1,2,5,6,9-21 
These studies differ in the design, sample size, and anaesthe-
sia region/technique. As a consequence, there are divergent 
results, favouring the use of computerized anaesthesia3,5-7,13 
or showing no difference between the two techniques.9,16-19,22
We are aware that a literature review23 and a recent 
systematic review24 on this subject have been published. 
Both papers evaluated the use of CCLAD in children and 
adults. The first one is a narrative review of randomized 
clinical trials, and the second one is a systematic review 
and meta‐analysis, with some shortcomings in the meth-
odology, particularly regarding the assessment of the risk 
bias of the included papers. Therefore, we understand that 
a systematic review focused on children is the best way to 
provide evidence in order to subsidize a clinical decision in 
paediatric dentistry.
A substantial decrease in the pain, and in the consequent 
anxiety/fear, during local anaesthesia is the main factor that 
would encourage the clinicians to adopt the computerized 
anaesthesia in their daily practices, since the equipment 
is costly when compared to the conventional anaesthesia. 
The good clinical practice dictates that all decisions should 
be made based on strong scientific evidence, showing an 
important and significant response that could actually in-
fluence on the quality of the treatment and the patient's 
behaviour related to local anaesthesia. The best evidence 
to support this decision is a systematic review and meta‐
analysis. However, to the knowledge of the authors, this 
is the first systematic review that addresses this topic re-
lated to the paediatric dental practice, which justifies the 
completion of this study. Therefore, this systematic re-
view and meta‐analysis aims to investigate whether local 
computerized anaesthesia decreases the pain and disrup-
tive behaviour in children when compared to conventional 
anaesthesia.
2 | MATERIAL AND METHODS
2.1 | Protocol and registration
This study was registered in PROSPERO (CRD42016037184) 
and followed the PRISMA guidelines.25 It was carried out at 
the State University of Ponta Grossa, Paraná, between May 
2017 and May 2019.
2.2 | Information sources and 
search strategy
The controlled vocabulary (MeSH terms) and free words 
in the search strategy were defined based on the following 
PICOS strategy:
1. Population (P): children undergoing dental treatment 
under local anaesthesia
2. Intervention (I): computerized local anaesthesia
3. Comparison (C): conventional local anaesthesia
4. Primary outcome (O): pain perception and children's be-
haviour during local anaesthesia
5. Study design (S): randomized clinical trials.
The search strategy was initially established for PubMed 
database, associating controlled vocabulary (MeSH terms) 
Why this paper is important to paediatric dentists
• The computerized localdental anaesthesia is a tech-
nique that intends to reduce the pain related to local 
injection of the anaesthetic solution, by controlling 
the time and pressure of the injection; consequently, 
the stress and anxiety associated to this procedure 
are reduced.
• The device is expensive, and its acquisition can 
only be justified by a significant decrease in pain 
related to local anaesthesia.
• This paper indicates that the pain is not reduced by 
the use of computerized local dental anaesthesia 
when compared with conventional technique, and 
therefore, until now, the acquisition of this device 
will add no advantage to the daily dental practice 
with regard to pain during local anaesthesia.
120 | SMOLAREK Et AL.
and free words. The boolean operator OR was used to com-
bine the terms in each PICO concept; the operator AND was 
used to combine the different PICO concepts (population, 
intervention, and comparison). The strategy was adapted to 
other electronic databases (Scopus, Web of Science, Latin 
American Literature of Health Sciences of the Americas and 
Caribbean—LILACS, Brazilian Library of Dentistry—BBO 
and Cochrane Library) (Table 1).
The grey literature was searched using the databases 
System for Information on Grey Literature in Europe (SIGLE) 
and Scholar Google. Abstracts from the annual conference 
of the International Association for Dental Research (IADR) 
(1990‐2018) were also searched. Dissertations and theses were 
searched using the ProQuest Dissertations and Theses Full‐
Text databases and the Periodicos Capes Theses database.
2.3 | Eligibility criteria
The studies included in this systematic review and meta‐anal-
ysis were randomized controlled trials (RCTs) with a parallel 
or cross‐over design that analysed the influence of computer-
ized anaesthesia on the intensity of pain and on the children's 
behaviour during local anaesthesia when compared to con-
ventional anaesthesia technique.
Studies were excluded if: (a) sedation techniques were used 
associated with local anaesthesia; (b) the sample included 
teenagers and adults; (c) computerized anaesthesia was not 
compared to a control (the conventional technique); (d) com-
puterized anaesthesia was used in conjunction with other pain 
reduction techniques such as electrodes and vibrations; (e) the 
paper was not written in English, Spanish, or Portuguese.
2.4 | Selection of the study and 
data extraction
The first phase of the selection of the papers to be included 
in the systematic review consisted in a screening of the re-
trieved papers based on title and abstracts according to the 
criteria already described. This was accomplished by two 
reviewers (PCS and ACRC). In case of duplicated papers, 
the study was considered once. If the analysis of the title and 
abstract prevented a decision for inclusion or exclusion of the 
paper, the full text was analysed.
The full text of the eligible papers was retrieved, and 
these studies received an identification code that consisted 
in the author's name and year of publication. The relevant 
information about the studies (study design, characteristics 
of the participants, type of anaesthetics, study groups, and 
outcomes) is shown on Table 2. It was collected in specific 
forms that were developed for this research and pilot tested 
to certify that the retrieved data were consistent with the re-
search question. Three researchers took part in the data ex-
traction (PCS, ACRC, and LMW).
2.5 | Risk of bias in individual studies
The Cochrane Collaboration tool for assessing risk of bias 
in randomized trials was used for the quality assessments 
of the trials, following the recommendations described 
in the Cochrane Handbook for Systematic Reviews of 
Interventions 5.1.026,27 (http://handb ook.cochr ane.org); 
this was accomplished by two independent reviewers (PCS 
and ACRC).
The Cochrane tool is based on six domains: adequate se-
quence generation, allocation concealment, blinding of the 
outcome assessors, incomplete outcome data, selective out-
come reporting, and other possible sources of bias. The judg-
ment for each domain consisted of recording ‘yes’ (low risk 
of bias), ‘no’ (high risk of bias), or ‘unclear’ (either lack of 
information or uncertainty about the potential for bias).
Two of the six domains in the Cochrane risk of bias tool 
were considered as key domains for this systematic review 
(sequence generation and allocation concealment).26 The 
papers were judged to be at ‘low’ risk of bias if they were 
judged as ‘low’ risk in both key domains. If one key domain 
was classified as ‘unclear’ or ‘high’ risk of bias, the study 
was considered at ‘unclear’ or ‘high’ risk of bias, respec-
tively. If there was any disagreement between the reviewers 
in judging the key domains, it was solved through discussion 
or by consulting a third reviewer (L. M. W.).
2.6 | Summary measures and 
Synthesis of the results
For the meta‐analysis, only studies classified as ‘low’ or ‘un-
clear’ risk in the key domains at study level were included.
Data from eligible studies about pain perception during 
anaesthesia were evaluated using standardized mean differ-
ence, since it was a continuous outcome, obtained using dif-
ferent pain scales to evaluate pain. Patient's behaviour results 
were reported with dichotomous or continuous data; there-
fore, this outcome was analysed using risk ratio and standard-
ized mean difference, respectively.
For all summary measures, the 95% confidence interval 
(CI) was used and random‐effects model was employed. 
Heterogeneity was assessed using the Cochran Q test and 
I2 statistics. All analyses were conducted using RevMan 
software (version 3, the Cochrane Collaboration, USA). 
Subgroup analysis was performed considering two groups: 
studies of low and unclear risk of bias.
2.7 | Assessment of the quality of evidence 
using GRADE
The quality of the evidence was assessed using the Grading of 
Recommendations Assessment, Development and Evaluation 
(GRADE)28 (http://www.grade worki nggro up.org/). This 
http://handbook.cochrane.org
http://www.gradeworkinggroup.org/
 | 121SMOLAREK Et AL.
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(C
on
tin
ue
s)
122 | SMOLAREK Et AL.
Pu
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T
A
B
L
E
 1
 
(C
on
tin
ue
d)
(C
on
tin
ue
s)
 | 123SMOLAREK Et AL.
Pu
bm
ed
 =
 6
26
9 
(0
5/
04
/2
01
9)
#1
 A
N
D
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2 
or
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3
 
C
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an
e 
Li
br
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=
 2
12
 (0
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04
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#1
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rim
ar
y 
de
nt
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on
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#2
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rim
ar
y 
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#3
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rim
ar
y 
to
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h’
#4
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irs
t t
ee
th
’
#5
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irs
t t
oo
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rim
ar
y 
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ol
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s’
#7
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er
m
an
en
t t
ee
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’
#8
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en
tit
io
n 
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rm
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#9
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ae
di
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ta
l p
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 o
r #
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 #
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5 
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6 
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9 
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 o
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#1
3 
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st
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’
#1
4 
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w
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#1
5 
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ui
ck
sle
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#1
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or
ph
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s’
#1
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en
ta
l a
ne
st
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sia
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#1
8 
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en
ta
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es
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oc
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oc
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th
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1 
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st
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ec
ta
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th
es
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’
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ta
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an
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ra
di
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l a
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st
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ra
di
tio
na
l a
na
es
th
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#2
9 
#1
3 
or
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14
 o
r 
#1
5 
or
 #
16
 
or
 #
17
 o
r 
#1
8 
or
 #
19
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r 
#2
0 
or
 
#2
1 
or
 #
22
 o
r 
#2
3 
or
 #
24
 o
r 
#2
5 
or
 #
26
 o
r 
#2
7 
or
 #
28
 
#3
0 
#1
2 
an
d 
#2
9
 
T
A
B
L
E
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(C
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tin
ue
d)
124 | SMOLAREK Et AL.
stage was accomplished to determine the overall strength of 
the evidence for each meta‐analysis. The evidence can be 
graded in four levels (very low, low, moderate, and high). 
When a meta‐analysis is graded as ‘high quality’, it means 
that the authors are very confident that the true effect lies 
close to the estimate of the effect. Factors that downgrade 
the quality include imprecision, inconsistency, indirectness, 
limitations, and bias of the evidence.29
3 | RESULTS
3.1 | Study selection
We found 8389 records in the databases in the first screen-
ing. After removal of duplicates, 7344 records remained. 
The title analysis reduced this number to 302 papers. After 
abstract reading, 272 were excluded. Therefore, 30 studies 
remained for full‐text analysis. From these, 10 were ex-
cluded for different reasons: (a) patients were sedated with 
nitrous oxide (n = 2)30,31; (b) there was no comparison be-
tween anaesthetic techniques (conventional vs. computer-
ized) (n = 7),4,8,10,11,17,32,33 (c) the papers were not written in 
English, Portuguese, or Spanish (n = 1)34 (Figure 1).
3.2 | Features of included papers
The characteristics of the 20 selected studies are listed in Table 
2. Twelve studies had parallel designs2,5-7,9,13,15,16,18-20,35 and 
7 cross‐over designs.1,3,12,14,21,36,37 And one mixed design 
parallel and cross‐over.4 The sample size ranged from 20 to 
158 children, with mean age of 8.41 ± 2.42 years.
The anaesthesia protocol for all studies included the use of 
topical anaesthetics previously local anaesthesia, except one 
that did not report.37 The topic anaesthetic drug was benzo-
caine in five studies,3,5,18,19,21 lidocaine spray in two,1,20 one 
study used lidocaine with prilocaine,12 another one used lido-
caine gel,7 and nine did not report.2,6,9,13-16,35,36
The most used anaesthetic solution for local anaesthesia 
was lidocaine 2% with epinephrine 1:100  000, which was 
used in 12 studies2,3,5-7,9,13,14,16,19,20; four studies used 2% li-
docaine with epinephrine 1:80 0007,18-20; three studies used 
2% mepivacaine with epinephrine 1:100 000,1,12,37 one used 
4% articaine with epinephrine 1:100 000,4 and two studies 
did not report which anaesthetic solution was used.15,35
As for the anaesthesia site, there was some variation be-
tween the studies. Twelve studies carried out local anaesthesia 
in the maxilla 1-3,6,13,14,16,18-21,37; three in the mandible,5,7,12 
and five in the maxilla and mandible.4,9,15,35,36
Most of the studies that used the mandible as the anaesthe-
sia site performed the inferior alveolar nerve block technique 
(IANB)4,5,9,12,15,35; only one used the infiltrative technique7 
for the conventional anaesthesia. For the computerized anaes-
thesia, three used periodontal ligament injection (PDL),5,15,35 
one infiltrative technique,7 two IANB technique,9,12 and one 
intraosseous technique.4 When the anaesthesia site was the 
maxilla, fifteen used the vestibular and palatine infiltra-
tive technique,1-4,6,9,13-16,18-21,35 and one PDL37 for the con-
ventional anaesthesia; for the computerized technique, six 
papers used anaesthetic techniques for anterior and middle 
superior nerve injection (AMSA),2,3,6,15,16,35 five used the 
palatal approach anterior superior alveolar nerve block (P‐
ASA),2,6,13,15,35 one PDL37 one intraosseous technique,4 and 
one study did not report.36
There was a great divergence in the methods of evaluation 
and the presentation of the data between the studies. For pain 
perception evaluation, eight studies used visual analog scale 
(VAS).1,2,4,9,12,14,15,20,35 Other scales used were Eland colour 
scale,3 Wong Baker Faces,5 Faces Pain Scale Revised,7 FIS 
Image Scale modified,36 NVRS (Numerical Visual Rating 
Scale).37
The disruptive behaviour of the patient related to the pain 
during anaesthesia was evaluated by seven articles using the 
code of behaviour of pain or disruptive behaviour2,5,6,9,13,15,35; 
two articles used ‘Sound, Eyes and Movement scale’3,20; the 
‘The Face, Legs, Activity, Cry, Consolability scale’ (FLACC) 
was used by two studies.7,36
3.3 | Risk assessment of bias
Six papers were classified as ‘low’,4,15,18,19,35,37 and fourteen 
articles were classified as ‘uncertain risk’ risk of bias1-3,5-
7,9,12-14,20,21,36 (Figure 2).
3.4 | Meta‐analysis
The meta‐analyzes were performed in studies classified at 
‘low’ or ‘unclear’ risk of bias from which the necessary infor-
mation could be extracted. The meta‐analyzes are shown on 
Figures 3, 4, and 5. We also performed a subgroup analysis 
to explore if the quality of included studies had any effect on 
the combined results.
A total of 16 articles were eligible for a meta‐analysis on 
pain perception during local anaesthesia, but the great vari-
ability on data report prevented us from using all of them. 
Therefore, only ten papers were used for this purpose; four 
were classified at low risk of bias,4,15,35,37 and six at unclear 
riskof bias.3,5,7,13,20,36 There was some incompatibility in the 
way the results were showed in some papers, which prevented 
us from collecting the data and made them unsuited for the 
meta‐analysis on pain perception and these papers were ex-
cluded.1,2,9,14,18,19 For the presence of patient's disruptive be-
haviour related to anaesthesia, 11 studies were eligible for 
meta‐analysis. For this outcome, five papers reported the 
outcome using continuous data and they were grouped in 
one meta‐analysis that used the standard mean differences 
3,7,20,35,36 and the other five studies reported as dichotomic 
 | 125SMOLAREK Et AL.
T
A
B
L
E
 2
 
R
el
ev
an
t i
nf
or
m
at
io
n 
ab
ou
t t
he
 st
ud
ie
s
A
ut
ho
r/
da
te
D
es
ig
n
A
ge
Sa
m
pl
e
To
ta
l n
um
be
r 
of
 
pa
tie
nt
s/m
al
es
To
pi
ca
l a
na
es
th
et
ic
/
tim
e 
(s
)
Lo
ca
l a
na
es
th
et
ic
/v
ol
-
um
e 
(m
L)
C
om
pu
te
ri
ze
d 
an
ae
st
he
sia
 a
rm
C
on
ve
nt
io
na
l 
an
ae
st
he
sia
 a
rm
O
ut
co
m
es
A
l A
m
ou
di
 e
t a
l, 
20
08
16
Pa
ra
lle
l
5‐
8
80
/3
6 
m
al
e
N
i/6
0
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
1
M
ax
ill
a:
 A
M
SA
M
ax
ill
a:
 In
fil
tra
tiv
e 
B
uc
ca
l a
nd
 P
al
at
al
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r i
n 
tre
at
-
m
en
tS
EM
 S
ca
le
A
lle
n 
et
 a
l, 
20
02
6
Pa
ra
lle
l
2‐
5
40
/3
1 
m
al
e
N
i/3
0
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
1
M
ax
ill
a:
 A
M
SA
 
ou
 P
‐A
SA
M
ax
ill
a:
 In
fil
tra
tiv
e 
B
uc
ca
l a
nd
 P
al
at
al
‐ D
is
ru
pt
iv
e 
be
ha
vi
ou
r
Pa
in
 b
eh
av
io
ur
 c
od
e
A
sa
rc
h 
et
 a
l, 
19
99
9
Pa
ra
lle
l
5‐
13
57
/N
i
N
i/3
0 
a 
45
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
 1
,1
M
an
di
bl
e:
 IA
N
B
M
ax
ill
a:
 
In
fil
tra
tiv
e 
bu
cc
al
 
an
d 
pa
la
ta
l
M
an
di
bl
e:
 IA
N
B
M
ax
ill
a:
 In
fil
tra
tiv
e 
bu
cc
al
 a
nd
 P
al
at
al
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r
D
is
ru
pt
iv
e 
be
ha
vi
ou
r c
od
e
B
ag
hl
af
 e
t a
l, 
20
15
5
Pa
ra
lle
l
5‐
9
91
/N
i
B
en
zo
ca
in
e/
N
i
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
1,
8
M
an
di
bl
e:
 
IA
N
B
 o
r 
In
tra
lig
am
en
ta
ry
M
an
di
bl
e:
 IA
N
B
• 
Pa
in
 p
er
ce
pt
io
nW
on
g 
B
ak
er
 
FA
C
ES
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r
Pa
in
 b
eh
av
io
ur
 c
od
e
D
ee
pa
k 
et
 a
l, 
20
17
7
Pa
ra
lle
l
6‐
10
10
0/
51
 m
al
e
Li
do
ca
in
e 
ge
l/6
0
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
80
 0
00
/1
M
an
di
bl
e:
 
In
fil
tra
tiv
e
M
an
di
bl
e:
 
In
fil
tra
tiv
e
• 
Pa
in
 p
er
ce
pt
io
nF
PS
‐R
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r
FL
A
C
C
• 
A
nx
ie
ty
M
C
D
A
S
Fe
da
 e
t a
l, 
20
10
3
C
ro
ss
‐
ov
er
7‐
10
40
/1
8 
m
al
e
B
en
zo
ca
in
e/
60
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
1
M
ax
ill
a:
 A
M
SA
M
ax
ill
a:
 In
fil
tra
tiv
e 
bu
cc
al
 a
nd
 P
al
at
al
• 
Pa
in
 p
er
ce
pt
io
nE
la
nd
 C
ol
ou
r 
Sc
al
e
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r
SE
M
 S
ca
le
G
ar
re
t‐B
er
na
rd
in
 
et
 a
l, 
20
17
1
C
ro
ss
‐
ov
er
7‐
15
67
/3
8 
m
al
e
Li
do
ca
in
e 
sp
ra
y/
N
i
2%
 m
ep
iv
ac
ai
ne
 
w
ith
 e
pi
ne
ph
rin
e 
1:
10
0 
00
0/
1,
8
M
ax
ill
a:
 
In
fil
tra
tiv
e 
bu
cc
al
 
an
d 
pa
la
ta
l o
r 
lin
gu
al
M
ax
ill
a:
 In
fil
tra
tiv
e 
bu
cc
al
 a
nd
 p
al
at
al
 
or
 li
ng
ua
l
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
• 
H
ea
rt 
ra
te
• 
St
re
ss
 a
nd
 a
nx
ie
ty
M
od
ifi
ed
 V
en
ha
m
 S
ca
le
• 
Sa
tis
fa
ct
io
n 
of
 p
at
ie
nt
s
G
ib
so
n 
et
 a
l, 
20
00
2
Pa
ra
lle
l
5‐
13
62
/3
2 
m
al
e
N
i/6
0
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
1,
4
M
ax
ill
a:
 A
M
SA
 
ou
 P
‐A
SA
M
ax
ill
a:
 In
fil
tra
tiv
e 
bu
cc
al
 a
nd
 p
al
at
al
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
• 
D
is
ru
pt
iv
e 
B
eh
av
io
ur
Pa
in
 b
eh
av
io
ur
 c
od
e
K
an
di
ah
 &
 
Ta
hm
as
se
bi
, 
20
12
19
Pa
ra
lle
l
8‐
16
30
/1
1 
m
al
e
B
en
zo
ca
in
e 
20
%
/1
20
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
80
 0
00
/1
,8
M
ax
ill
a:
 
In
fil
tra
tiv
e 
of
 
fir
st
 m
ol
ar
M
ax
ill
a:
 In
fil
tra
tiv
e 
of
 fi
rs
t m
ol
ar
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
• 
Pu
lp
ar
 a
na
es
th
es
ia
Pu
lp
 te
st
(C
on
tin
ue
s)
126 | SMOLAREK Et AL.
A
ut
ho
r/
da
te
D
es
ig
n
A
ge
Sa
m
pl
e
To
ta
l n
um
be
r 
of
 
pa
tie
nt
s/m
al
es
To
pi
ca
l a
na
es
th
et
ic
/
tim
e 
(s
)
Lo
ca
l a
na
es
th
et
ic
/v
ol
-
um
e 
(m
L)
C
om
pu
te
ri
ze
d 
an
ae
st
he
sia
 a
rm
C
on
ve
nt
io
na
l 
an
ae
st
he
sia
 a
rm
O
ut
co
m
es
K
le
in
 e
t a
l, 
20
05
13
Pa
ra
lle
l
3‐
5
21
/1
1 
m
al
e
N
i/3
0
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
1,
8
M
ax
ill
a:
 P
‐A
SA
M
ax
ill
a:
 In
fil
tra
tiv
e 
bu
cc
al
 a
nd
 p
al
at
al
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
rA
D
B
C
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r i
n 
tre
at
m
en
t
A
D
B
C
M
itt
al
 e
t a
l, 
20
15
20
Pa
ra
lle
l
8‐
12
10
0/
54
 m
al
e
Li
do
ca
in
e 
sp
ra
y/
60
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
80
 0
00
/1
,1
M
ax
ill
a:
 
In
fil
tra
tiv
e 
bu
cc
al
 
an
d 
pa
la
ta
l
M
ax
ill
a:
 In
fil
tra
tiv
e 
bu
cc
al
 a
nd
 p
al
at
al
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r
SE
M
 S
ca
le
Pa
lm
 e
t a
l, 
20
04
12
C
ro
ss
‐
ov
er
7‐
18
33
/1
5 
m
al
e
Li
do
ca
in
e 
+
 P
ril
oc
ai
ne
/6
0
2%
 m
ep
iv
ac
ai
ne
 
w
ith
 e
pi
ne
ph
rin
e 
1:
10
0 
00
0/
1,
5
M
an
di
bl
e:
 IA
N
B
M
an
di
bl
e:
 IA
N
B
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
Pa
tin
i e
t a
l, 
20
18
37
C
ro
ss
‐
ov
er
5‐
12
76
/3
8 
m
al
e
N
i
2%
 m
ep
iv
ac
ai
ne
 
w
ith
 e
pi
ne
ph
rin
e 
1:
10
0 
00
0/
1,
8
M
ax
ill
a:
 
In
tra
lig
am
en
ta
ry
M
ax
ill
a:
 
In
tra
lig
am
en
ta
ry
• 
Pa
in
 p
er
ce
pt
io
nN
V
R
S 
(N
um
er
ic
al
 V
is
ua
l R
at
in
g 
Sc
al
e)
• 
H
ea
rt 
ra
te
Q
ue
iro
z 
et
 a
l, 
20
15
21
C
ro
ss
‐
ov
er
7‐
12
20
/N
i
B
en
zo
ca
in
e/
18
0
4%
 a
rti
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
1,
8
M
ax
ill
a:
 
In
fil
tra
tiv
e 
of
 
fir
st
 m
ol
ar
M
ax
ill
a:
 In
fil
tra
tiv
e 
of
 fi
rs
t m
ol
ar
‐ S
tre
ss
 a
nd
 a
nx
ie
ty
C
or
tis
ol
 sa
liv
a
ST
A
IC
Sa
n 
M
ar
tín
 L
op
ez
 
et
 a
l, 
20
05
14
C
ro
ss
‐
ov
er
9‐
12
64
/3
0 
m
al
e
N
i/6
0
2%
 li
do
ca
in
e 
w
ith
 
ep
in
ep
hr
in
e 
1:
10
0 
00
0/
1,
35
M
ax
ill
a:
 
In
fil
tra
tiv
e 
of
 
bu
cc
al
 a
nd
 
pa
la
ta
l
M
ax
ill
a:
 In
fil
tra
tiv
e 
of
 b
uc
ca
l a
nd
 
pa
la
ta
l
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
• 
H
ea
rt 
ra
te
Sm
ai
l‐F
au
ge
ro
n 
et
 a
l, 
20
19
4
Pa
ra
lle
l 
an
d 
cr
os
s‐
ov
er
7‐
15
15
8/
62
 m
al
e
X
yl
oc
ai
ne
 2
%
/6
0‐
12
0
4%
 a
rti
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0
M
ax
ill
a:
 
In
tra
os
se
ou
s
M
an
di
bl
e:
 
In
tra
os
se
ou
s
M
ax
ill
a:
 In
fil
tra
tiv
e
M
an
di
bl
e:
 IA
N
B
• 
Pa
in
 p
er
ce
pt
io
nV
A
S
Ta
hm
as
se
bi
; 
N
ik
ol
ao
u;
 
D
ug
ga
l, 
20
09
18
Pa
ra
lle
l
3‐
10
38
/N
i
B
en
zo
ca
in
e/
12
0
‐2
%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
80
 0
00
/N
i
M
ax
ill
a:
 
In
fil
tra
tiv
e 
of
 
bu
cc
al
 a
nd
 
pa
la
ta
l
M
ax
ill
a:
 In
fil
tra
tiv
e 
of
 b
uc
ca
l a
nd
 p
al
a-
ta
l i
nt
ra
pa
pi
lla
ry
• 
Pa
in
 p
er
ce
pt
io
nV
A
S 
m
od
ifi
ca
da
• 
St
re
ss
 a
nd
 a
nxie
ty
V
PT
T
A
B
L
E
 2
 
(C
on
tin
ue
d)
(C
on
tin
ue
s)
 | 127SMOLAREK Et AL.
A
ut
ho
r/
da
te
D
es
ig
n
A
ge
Sa
m
pl
e
To
ta
l n
um
be
r 
of
 
pa
tie
nt
s/m
al
es
To
pi
ca
l a
na
es
th
et
ic
/
tim
e 
(s
)
Lo
ca
l a
na
es
th
et
ic
/v
ol
-
um
e 
(m
L)
C
om
pu
te
ri
ze
d 
an
ae
st
he
sia
 a
rm
C
on
ve
nt
io
na
l 
an
ae
st
he
sia
 a
rm
O
ut
co
m
es
Th
op
pe
‐
D
ha
m
od
ha
ra
n 
et
 
al
, 2
01
536
C
ro
ss
‐
ov
er
7‐
11
12
0/
71
 m
al
e
N
i/3
0
2%
 li
do
ca
in
e 
w
ith
 e
pi
-
ne
ph
rin
e 
1:
10
0 
00
0/
N
i
M
ax
ill
a:
 N
i
M
an
di
bl
e:
 N
i
M
ax
ill
a:
 N
i
M
an
di
bl
e:
 N
i
• 
Pa
in
 p
er
ce
pt
io
nF
IS
 m
od
ifi
ed
• 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r
FL
A
C
C
‐H
ea
rt 
ra
te
V
er
sl
oo
t e
t a
l, 
20
05
15
Pa
ra
lle
l
4‐
11
12
5/
68
 m
al
e
N
i/N
i
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ill
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ou P‐
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an
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ax
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 In
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of
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pa
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ou P‐
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 In
fil
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of
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nd
 
pa
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• 
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in
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nV
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Pa
in
 B
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av
io
ur
 c
od
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• 
St
re
ss
 a
nd
 a
nx
ie
ty
V
PT
C
FS
S‐
D
S
A
bb
re
vi
at
io
ns
: A
D
B
C
, a
nx
io
us
 a
nd
 d
is
ru
pt
iv
e 
be
ha
vi
ou
r c
od
e;
 A
M
SA
, a
nt
er
io
r a
nd
 m
id
dl
e 
su
pe
rio
r a
lv
eo
la
r n
er
ve
 b
lo
ck
; C
FS
S‐
D
S,
 D
en
ta
l S
ub
sc
al
e 
C
hi
ld
re
n'
s F
ea
r S
ur
ve
y 
Sc
he
du
le
; F
IS
, F
ac
ia
l I
m
ag
e 
Sc
al
e;
 F
LA
C
C
, f
ac
e,
 
le
gs
, a
ct
iv
ity
, c
ry
, c
on
so
la
bi
lit
y;
 F
PS
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, F
ac
es
 p
ai
n 
sc
al
e-
R
ev
is
ed
 (F
PS
-R
); 
IA
N
B
, i
nf
er
io
r a
lv
eo
la
r n
er
ve
 b
lo
ck
; M
C
D
A
S,
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od
ifi
ed
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hi
ld
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en
ta
l A
nx
ie
ty
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ac
es
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ca
le
 si
m
pl
ifi
ed
; N
.i.
, n
ot
 in
fo
rm
ed
; P
‐A
SA
, p
al
at
al
 a
pp
ro
ac
h 
an
te
rio
r s
up
er
io
r a
lv
eo
la
r n
er
ve
 b
lo
ck
; P
D
L,
 p
er
io
do
nt
al
 li
ga
m
en
t i
nj
ec
tio
n;
 S
EM
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ca
le
, s
ou
nd
, e
ye
s, 
an
d 
m
ov
em
en
t s
ca
le
; S
TA
IC
, S
ta
te
 T
ra
it 
A
nx
ie
ty
 In
ve
nt
or
y 
fo
r C
hi
ld
re
n;
 V
A
S,
 V
is
ua
l a
na
lo
gu
e 
sc
al
e;
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PT
, V
en
ha
m
 p
ic
tu
re
 
te
st
.
T
A
B
L
E
 2
 
(C
on
tin
ue
d)
128 | SMOLAREK Et AL.
data and they were analysed using risk ratio as effect mea-
sure.2,5,6,9,15 Among them, two were classified as low risk of 
bias15,35 and eight classified as unclear risk of bias.2,3,5-7,9,20,36 
The excluded paper showed different methodology for deter-
mination of disruptive behaviour, and the data were not used 
in the meta‐analysis.13
F I G U R E 1 Flow diagram of study identification
Id
en
�fi
ca
�o
n 
Sc
re
en
in
g
El
ig
ib
ili
ty
 
In
cl
ud
ed
 
Records iden�fied through 
database searching 
(n = 8.389) 
Records a�er duplicates remove 
Endnote (n = 7.334) 
Records excluded 
a�er �tle screen 
(n = 7.042) 
Records screened 
(n = 302) 
Records excluded a�er abstract 
screen (n = 272) 
Full-text ar�cles assessed 
for eligibility 
Studies excluded (n = 10): 
• Pa�ents sedated with nitrous oxide (n = 2). 
• There is no comparison between anaesthe�c
techniques conven�onal vs. computerized 
(n = 7) 
• Not wri�en in English or Spanish or Portuguese 
(n = 1) 
Studies included in 
qualita�ve synthesis 
Pubmed: 6.269 
(20/12/2017)
Scopus: 914 
(10/05/2016)
Web: 264 
(10/05/2016)
Lilacs/BBO: 730 
(16/05/2016)
Cochrane: 212 
(16/05/2016)
Studies included in 
quan�ta�ve synthesis 
(meta-analysis) 
(n = 17) 
Studies not included in the meta-
analysis (n = 3) 
* Incompa�bility of scales for determina�on of 
pain percep�on and/or disrup�ve behaviour (n = 3) 
(n = 30)
(n = 20)
 | 129SMOLAREK Et AL.
F I G U R E 2 Summary of the risk of bias assessment according to the Cochrane Collaboration tool
130 | SMOLAREK Et AL.
3.5 | Perception of Pain
This analysis was based on 10 papers comparing computer-
ized to conventional anaesthesia.3-5,7,12,15,20,35-37 The over-
all analysis resulted in a standard mean difference of −0.78 
(95% CI = −1.31 to −0.25; I2 = 94%). The standard mean 
difference was −0.12 (95% CI = −0.46 to‐0.22; P = .48) for 
the subgroup'low risk’4,15,35,37 (Figure 3); data were hetero-
geneous (χ2 = 13.24; df = 3, P = .004; I2 = 77%). When only 
the papers judged as ‘unclear’, risk were analysed, the stand-
ard mean diffrence was −1.27 ( – 95% CI = −2.21 to −0.33; 
P  =  .008); data were also heterogeneous (χ2  =  115.74, 
df = 5, P fear that can 
alter the perception of pain. In the infant universe, it is even 
more difficult to understand how much pain the child feels 
at any given moment or stimulus, how anxious, stressed, or 
frightened he/she is, and how it will influence the pain per-
ception.1 Therefore, perception of pain and behaviour during 
local anaesthesia is related to children's emotional factors. 
These factors, by themselves, may be responsible for some 
degree of the inherent clinical heterogeneity of the trials. 
However, we can also list a few other features that probably 
contribute to the high degree of heterogeneity and the poor 
quality of evidence found in our meta‐analysis of pain during 
local anaesthesia, such as the variety of pain measurement 
scales and the age range studied.
The studies reported here measured pain during local 
anaesthesia using different pain scales, all of them depen-
dent on the patient's report. This is the method taken as the 
‘gold standard’ for pain assessment in children.39 The pain 
scales consisted of various versions of the visual analog sc
ales,1,2,4,9,12,14,15,18-20,35 Wong Baker FACES,5 Faces Pain 
Scale—revised,7 Eland Colour Scale,3 numerical verbal rating 
scales,37 and Facial Image Scale.36 They are designed to assess 
different levels of pain, and they are all validated to evaluate 
pain in children.9 Even considering the different scales used 
by the authors, the results of the studies could be grouped 
because they were summarized by calculating the Hedge's g 
standardized mean difference. By doing so, all the results are 
transformed to a common scale and they become comparable. 
However, it can contribute to increase heterogeneity.
For the perception of pain, the meta‐analysis showed a 
lower perception of pain in children who received comput-
erized anaesthesia. However, a high level of heterogeneity 
was detected (I2  =  94%). The better performance of the 
computerized anaesthesia regarding pain perception was not 
F I G U R E 5 Meta‐analysis of disruptive behaviour—dichotomy data—subgroup analysis according to the risk of bias
132 | SMOLAREK Et AL.
T
A
B
L
E
 3
 
Su
m
m
ar
y 
of
 fi
nd
in
gs
 ta
bl
e—
G
R
A
D
E
C
er
ta
in
ty
 a
ss
es
sm
en
t
№
 o
f p
at
ie
nt
s
Ef
fe
ct
C
er
ta
in
ty
Im
po
rt
an
ce
№
 o
f 
st
ud
ie
s
St
ud
y 
de
sig
n
R
isk
 o
f 
bi
as
In
co
ns
ist
en
cy
In
di
re
ct
ne
ss
Im
pr
ec
isi
on
O
th
er
 
co
ns
id
er
at
io
ns
co
m
pu
te
ri
ze
d
co
nv
en
-
ci
on
al
 
an
ae
st
he
sia
R
el
at
iv
e 
(9
5%
 C
I)
A
bs
ol
ut
e 
(9
5%
 C
I)
Pa
in
 p
er
ce
pt
io
n 
re
la
te
d 
w
ith
 c
om
pu
te
riz
ed
 a
nd
 c
on
ve
nc
io
na
l a
ne
st
he
si
a—
pa
tie
nt
‐r
el
at
ed
 o
ut
co
m
e 
(a
ss
es
se
d 
w
ith
: V
is
ua
l A
na
lo
gu
e 
Sc
al
e 
(V
A
S)
, F
ac
es
 P
ai
n 
Sc
al
e‐
R
ev
is
ed
 (F
PS
‐R
), 
W
on
g‐
B
ak
er
 
FA
C
ES
 P
ai
n 
R
at
in
g 
Sc
al
e,
 M
od
ifi
ed
 F
ac
ia
l I
m
ag
e 
Sc
al
e 
(F
IS
), 
V
is
ua
l R
at
in
g 
Sc
al
e 
an
d 
N
um
er
ic
al
 R
at
in
g 
Sc
al
e 
(V
N
R
S)
)
10
ra
n- do
m
is
ed
 
tri
al
s
se
rio
us
 a
se
rio
us
 b
no
t s
er
io
us
no
t s
er
io
us
no
ne
56
5
56
7
‐
SM
D
 
0.
76
 S
D
 
lo
w
er
(1
.2
9 
lo
w
er
 
to
 0
.2
3 
hi
gh
er
)
⨁
⨁
◯
◯
LO
W
C
R
IT
IC
A
L
D
is
ru
pt
iv
e 
be
ha
vi
ou
r r
el
at
ed
 to
 c
om
pu
te
riz
ed
 a
nd
 c
on
ve
nc
io
na
l a
ne
st
he
si
a—
di
ch
ot
om
ou
s d
at
a 
(a
ss
es
se
d 
w
ith
: d
is
ru
pt
iv
e 
be
ha
vi
ou
r c
od
e,
pa
in
 b
eh
av
io
ur
 c
od
e)
5
ra
n- do
m
is
ed
 
tri
al
s
se
rio
us
 a
se
rio
us
 c
no
t s
er
io
us
se
rio
us
 d
no
ne
13
7/
27
6 
(4
9.
6%
)
15
5/
26
8 
(5
7.
8%
)
no
t e
st
i-
m
ab
le
 
⨁
◯
◯
◯
V
ER
Y
 
LO
W
IM
PO
R
TA
N
T
0.
0%
 
D
is
ru
pt
iv
e 
be
ha
vi
ou
r r
el
at
ed
 to
 c
om
pu
te
riz
ed
 a
nd
 c
on
ve
nt
io
na
l a
ne
st
he
si
a—
co
nt
in
uo
us
 d
at
a 
(a
ss
es
se
d 
w
ith
: F
LA
A
C
, S
EM
 S
ca
le
, p
ai
n 
be
ha
vi
ou
r c
od
e)
5
ra
n- do
m
is
ed
 
tri
al
s
se
rio
us
 a
se
rio
us
 e
no
t s
er
io
us
se
rio
us
 d
no
ne
26
6
27
4
‐
SM
D
 
0.
26
 S
D
 
lo
w
er
(0
.6
8 
lo
w
er
 
to
 0
.1
6 
hi
gh
er
)
⨁
◯
◯
◯
V
ER
Y
 
LO
W
IM
PO
R
TA
N
T
A
bb
re
vi
at
io
ns
: C
I, 
co
nf
id
en
ce
 in
te
rv
al
; S
M
D
, s
ta
nd
ar
di
ze
d 
m
ea
n 
di
ff
er
en
ce
.
Ex
pl
an
at
io
ns
: a
. M
os
t s
tu
di
es
 w
er
e 
cl
as
si
fie
d 
as
 u
nc
le
ar
 fo
r t
he
 ‘a
llo
ca
tio
n 
co
nc
ea
lm
en
t’ 
an
d 
‘s
eq
ue
nc
e 
ge
ne
ra
tio
n’
; b
. U
ne
xp
la
in
ed
 h
et
er
og
en
ei
ty
 (P
 at 
unclear risk of bias.2,3,5-7,9,20,36
The blocking of the nervous stimulation by dental anaes-
thesia decreases the central nervous system response to pain-
ful stimuli, also decreasing the patient's anxiety during dental 
treatment. Nevertheless, the greater the dental anxiety, the 
greater the non‐cooperative behaviour40 and the difficulty to 
manage children's behaviour. Considering this, some authors 
also evaluated the stress and anxiety during conventional and 
computerized anaesthesia1,15,18,21,35 and no difference was re-
ported. It was found that high anxious children tend to feel 
more pain during local anaesthesia, irrespective the anaes-
thetic technique used.35 Unfortunately, it was not possible to 
extract the data related to stress and anxiety from these pa-
pers, since evaluation criteria were very different from one to 
another, which prevented the meta‐analysis.
In addition to the factors already described, there are con-
ditions that can influence the pain response and disruptive 
behaviour,36 such as the site of the anaesthesia. For exam-
ple, the IANB method is considered very painful; an injec-
tion into the palate is even more painful.33 This may affect 
the child's behaviour and perception of pain. In the included 
studies, the majority of the papers compared the injections 
in the maxilla.1-4,6,13,14,16,18-21,37 It is a less challenging an-
aesthetic technique to perform when compared to the IANB, 
since there are fewer anatomical variations in the maxilla. 
However, there were studies that compared not only differ-
ent anaesthetic methods, but also different anaesthetic techni
ques,2-4,6,9,13,15,16,18,35,36 which interfere in pain perception 
and disruptive behaviour in children. By doing so, the study 
design added not only another variable, but also a possible 
bias; therefore, the results should be interpreted cautiously. 
This may be another source of heterogeneity, as detected by 
the meta‐analysis. Therefore, if the focus is the evaluation of 
the anaesthetic method (for instance computerized vs. con-
ventional), future clinical trial must considered the use of the 
same anaesthetic technique.
Irrespective of the selected anaesthetic technique or 
anaesthetic method, a suitable approach for managing the 
infant patient is essential. The expertise and training of the 
dentist in anaesthetizing a child are very important and 
may modify the perception of pain during the procedure. 
The paediatric dentist should establish a dialogue with the 
child so that he/she feels safe and confident. It is necessary 
to recognize the child's psychological profile and to use 
the most appropriate behaviour management techniques 
in dental treatment, improving the child's coping skills,41 
since manipulating attention or emotion can positively af-
fect the experience of pain.42 Likewise, anaesthesia should 
be performed according to the protocol of each technique, 
negligencing the recommendations may contribute to fear 
and dental anxiety.
According to this systematic review and meta‐analysis, we 
do not consider that investing on a CCLAD, with the objec-
tive of reducing pain and disruptive behaviour related to local 
anaesthesia in children, is a wise choice, since conventional 
injection performed correctly may have similar results. We 
strongly suggest that new randomized clinical trials should 
be accomplished with well‐defined methodology in order to 
improve the quality of the evidence.
134 | SMOLAREK Et AL.
5 | CONCLUSION
There is no difference in the perception of pain and disruptive 
behaviour in children subjected to computerized or conven-
tional dental local anaesthesia. Notwithstanding, the qual-
ity of the available evidence is low and further research is 
needed to corroborate this finding.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
AUTHORS' CONTRIBUTION
Priscila de Camargo Smolarek, Letícia M. Wambier, 
Leonardo Siqueira Silva, and Ana Cláudia Rodrigues 
Chibinski conceived and/or designed the work that led to the 
submission, acquired data, and played an important role in 
interpreting the results. Priscila de Camargo Smolarek and 
Ana Cláudia Rodrigues Chibinski drafted or revised the 
manuscript. Priscila de Camargo Smolarek, Letícia Maira 
Wambier, and Ana Cláudia Rodrigues Chibinski approved 
the final version.
ORCID
Priscila de Camargo Smolarek  https://orcid.
org/0000-0001-7845-0261 
Letícia M. Wambier  https://orcid.
org/0000-0002-9696-0406 
Ana Cláudia Rodrigues Chibinski  https://orcid.
org/0000-0001-7072-9444 
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https://orcid.org/0000-0001-7845-0261
https://orcid.org/0000-0001-7845-0261
https://orcid.org/0000-0001-7845-0261
https://orcid.org/0000-0002-9696-0406
https://orcid.org/0000-0002-9696-0406
https://orcid.org/0000-0002-9696-0406
https://orcid.org/0000-0001-7072-9444
https://orcid.org/0000-0001-7072-9444
https://orcid.org/0000-0001-7072-9444
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How to cite this article: Smolarek PDC, Wambier 
LM, Silva LS, Chibinski ACR. Does computerized 
anaesthesia reduce pain during local anaesthesia in 
paediatric patients for dental treatment? A systematic 
review and meta‐analysis. Int J Paediatr Dent. 
2020;30:118–135. https ://doi.org/10.1111/ipd.12580 
https://doi.org/10.1111/ipd.12580