Effective local anaesthesia is important for the delivery of pain free dental procedures. However, pain during giving anaesthesia can be an issue. A number of different computer‐controlled local anaesthetic delivery (CCLAD) systems are in place which may be helpful in reducing pain during anaesthesia.
The aim of this review was to assess whether local computerised anaesthesia decreases the pain and disruptive behaviour in children when compared to conventional anaesthesia.
Methods
Searches were conducted in the PubMed, Scopus, Web of Science, Latin American Literature of Health Sciences of the Americas and Caribbean—LILACS, Brazilian Library of Dentistry—BBO, the Cochrane Library, System for Information on Grey Literature in Europe (SIGLE) Scholar Google, the ProQuest Dissertations and Theses Full‐ Text databases and the Periodicos Capes Theses database and the annual conference of the International Association for Dental Research (IADR) (1990‐2018). Randomised controlled trials (RCTs) of parallel or cross-over design assessing the influence of computerised anaesthesia on the intensity of pain and on the children’s behaviour during local anaesthesia compared to conventional anaesthesia techniques were considered. Papers written in English, Portuguese or Spanish were included.
Two reviewers selected papers extracted data and assessed risk of bias using the Cochrane tool. Dichotomous data was reported using risk ratios (RR) and 95% confidence intervals (CI) and continuous data with standardised mean difference (SMD) and 95%CIs. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess overall quality(certainty) of evidence.
Results
- 20 RCTs (12 parallel, 7 cross-over and one mixed design) involving 1,474 patients were included.
- All 20 studies used topical anaesthesia.
- 12 studies used lidocaine 2% with epinephrine 1:100 000, 4 studies 2% lidocaine with epinephrine 1:80 000. 3 studies 2% mepivacaine with epinephrine 1:100 000, one 4% articaine with epinephrine 1:100 000 with 2 not reporting which anaesthetic.
- 3 studies involve the maxillae, 3 the mandible and 5 both maxilla and mandible.
- A wide range of scale were used to evaluate pain and disruptive behaviour.
- 6 RCTS were considered to be at low risk of bias and 14 at uncertain risk.
- Pain perception
- Meta-analysis (10 studies) showed a reduction in pain perception in favour of computerised anaesthesia but no difference when only low risk studies (4 studies) were included.
- The certainty of the evidence for pain perception was considered to be low.
| No. of studies | Standard mean difference (95%CI) | |
| Overall | 10 | −0.78 (−1.31 to −0.25) |
| ‘Low risk’ studies | 4 | −0.12 (−0.46 to 0.22) |
| ‘Unclear risk’ studies | 6 | −1.27 (−2.21 to −0.33) |
- Disruptive behaviour
- 5 studies presented patient data using continuous measures with meta-analysis finding no differences between computerised and conventional approaches, SMD = −0.26 (95%CI; −0.68 to 0.16).
- Meta-analysis of 5 studies using dichotomous measures also demonstrated no differences between computerised and conventional approaches, RR = 0.81 (95%CI; 0.62 to 1.06
- The certainty of the evidence for disruptive behaviour was considered to be very low.
Conclusions
The authors concluded: –
There is no difference in the perception of pain and disruptive behaviour in children subjected to computerized or conventional dental local anaesthesia. Notwithstanding, the quality of the available evidence is low and further research is needed to corroborate this finding.
Comments
The authors registered their review protocol on PROSPERO and undertook a search of a wide selection on databases. However, restricting the included studies to just 3 languages (English, Portuguese or Spanish) may have excluded some relevant studies. 20 RCTs were included with 17 contributing to the meta-analyses. While the authors considered none of the studies to be at high risk of bias the risk of bias table shows that while 4 RCTs had low risk of bias for all 5 domains assessed 8 had high risk of bias for blinding with 8 having one or more domains at unclear risk of bias , most commonly related to allocation concealment.
While the overall meta-analyses for pain and disruptive behaviours suggested no difference between computerised and conventional approaches it is perhaps interesting to note that for the pain outcome when only the low risk studies were included in the meta-analysis the findings favoured the computerised approach. Further high quality and well reported studies are required to assess which is the best anaesthetic approach although as the authors note irrespective of the technique a suitable approach for managing the paediatric patients is important.
Links
Primary Paper
Smolarek PC, Wambier LM, Siqueira Silva L, Chibinski ACR. Does computerized anaesthesia reduce pain during local anaesthesia in paediatric patients for dental treatment? A systematic review and meta-analysis [published online ahead of print, 2019 Oct 8]. Int J Paediatr Dent. 2019;10.1111/ipd.12580. doi:10.1111/ipd.12580
Other references
Dental Elf – Local anaesthesia blogs
