Local anaesthetic for dental treatment: interventions to improve acceptance in children


Dental caries remains a significant problem in children despite being a preventable disease. One dentinal caries is established restoration or  surgical approaches are needed and these traditionally require local anaesthesia for the delivery of pain-free dentistry which is important to reduce fear and anxiety, facilitate treatment and develop a good dentist/patient relationship.

The aim of this Cochrane review was to evaluate methods for the acceptance of local anaesthesia (LA) in children and adolescents during dental treatment.


Searches were conducted in the Cochrane Oral Health’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, Web of Science, the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and World Health Organization International Clinical Trials Registry Platform with no restrictions on language or date of publication.  Parallel randomised controlled trials (RCTs) of interventions used to increase acceptance of dental LA in children and adolescents under the age of 18 years were considered.  THe primary outcome was acceptance of LA (yes/no). Standard Cochrane methodological procedures for data selection, assessment and analysis were followed.


  • 26 RCTs involving 2435 patients were included.
  • Studies were conducted in Egypt, France, India, Iran, Korea, Mexico, the Netherlands, Saudi Arabia, Syria, the UK and USA.
  • Only 1 study was considered to be at low risk of bias the remainder at high risk.
  • Meta-analysis was not possible because of clinical heterogeneity of the included studies.
  • None of the included studies reported on the primary outcome of acceptance of LA or the secondary outcomes of completion of dental treatment, successful LA/painless treatment, patient satisfaction, parent satisfaction, and adverse events.
  • Audiovisual distraction compared to conventional treatment: 1 RCT (60 patients) provided very low certainty evidence for a reduction in negative behaviour when 3D video glasses where used in the audiovisual distraction group; risk ratio (RR) =0.13 (95%CI; 0.03 to 0.50).
  • The wand versus conventional treatment: Very low certainty evidence from 6 RCTs (704 patients) with 4 RCTs reporting a benefit in using the wand while 2 studies results suggested no difference between the two methods of delivering LA
  • Counter-stimulation/distraction versus conventional treatment: 1 RCT (134 patients) providing very low certainty evidence of less pain when counter-stimulation was used; RR = 0.12 (95%CI; 0.04 to 0.34).
  • Hypnosis versus conventional treatment: 1 RCT (29 patients) provided very low certainty evidence for patients in the hypnosis group experiencing less pain (mean difference (MD)= -1.79 (95%CI; -3.01 to -0.57).
  • Findings from other comparisons (pre-cooling of the injection site, the wand versus Sleeper One, the use of a camouflage syringe, use of an electrical counter-stimulation device, and video modelling acclimatisation were insufficient to draw conclusions about their effectiveness.


The authors concluded: –

We did not find sufficient evidence to draw firm conclusions as to the best interventions to increase acceptance of LA in children due to variation in methodology and nature/timing of outcome measures. We recommend further parallel RCTs, reported in line with the CONSORT Statement. Care should be taken when choosing outcome measures.


While dental caries is almost completely preventable it is likely that LA will still be required for dental procedure in paediatric dentistry for some time. However, as this review demonstrates the quality of the evidence on increasing the evidence for the acceptance of LA is very low. All but one of the included studies was at high risk of bias for at least one of the risk of bias domains.  And while a number the secondary outcomes (pain on injection (measured by pain perception or experience), self- or observational assessments of intraoperative distress/pain/ acceptance of treatment and pre or postoperative anxiety measures (measured using physiological assessments, questionnaires, anxiety scales, and behavioural assessment) were assessed none of the included studies reported on the authors primary outcome of acceptance of local anaesthetic. The authors also noted wide discrepancy in intervention methodologies and outcome assessment time points making comparisons difficult. Additional high quality well reported trials are needed to clarify the best interventions to increase acceptance of local anaesthetic.

A recently published review (Dental Elf – 6th Dec 2019) of computerised versus conventional local anaesthesia in children suggesting no difference between the approaches. That review included 20 studies several of which were of cross-over design which the Cochrane authors suggest should not be used for this type of research as the level of anxiety may be influenced by the first intervention.


Primary Paper

Monteiro J, Tanday A, Ashley PF, Parekh S, Alamri H. Interventions for increasing acceptance of local anaesthetic in children and adolescents having dental treatment. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD011024.DOI: 10.1002/14651858.CD011024.pub2.

Other references

Dental Elf – 6th Dec 2019

Computerised local anaesthesia in paediatric patients










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