Inhalation Conscious Sedation with Nitrous Oxide and Oxygen as Alternative to General Anesthesia in Precooperative, Fearful, and Disabled Pediatric Dental Patients: A Large Survey on 688 Working Sessions

Efficacy and Safety of Nitrous Oxide (N2O) Inhalation Sedation Compared to Other Sedative Agents in Dental Procedures: A Systematic Review with Meta-Analysis

Background and Objectives: Dental procedures can be distressing, particularly for patients who are anxious or uncooperative. In such cases, effective sedation not only facilitates the clinician's work but also enhances patient comfort and acceptance of dental care. Nitrous oxide (N2O) has been widely employed as a sedative agent in dental practice. This systematic review aimed to assess the efficacy and safety of N2O compared to alternative sedative agents and techniques in dental surgical procedures. Materials and Methods: This review protocol was prospectively registered on PROSPERO (CRD42020213429) and conducted in accordance with PRISMA guidelines. Results: A total of 1809 records were screened (1134 from Embase, 638 from PubMed, and 37 from CENTRAL). The meta-analysis focused on the following three primary outcomes: 1. Patient satisfaction: Eight studies comprising 422 participants (165 treated with N2O and 176 with other sedatives) were included. 2. Recall of the procedure: Five studies with a total of 288 patients (68 receiving N2O and 64 other agents) assessed patients' ability to recall tooth extraction. 3. Successful completion of the procedure: Three studies involving 1578 patients (434 treated with N2O and 989 with alternative sedation methods) were analyzed. Conclusions: No statistically significant differences were observed between N2O and other sedative techniques across all outcomes evaluated. Safety could not be adequately assessed as none of the included studies systematically investigated this outcome. Further high-quality research is warranted to rigorously evaluate the safety profiles of various sedation strategies in dental surgery.

Effectiveness and predictive factors of nitrous oxide and oxygen inhalation sedation for paediatric dental procedures: a retrospective cohort study of Thai children

PURPOSE

To investigate the effectiveness and predictive factors of nitrous oxide and oxygen inhalation sedation (NOIS) in Thai paediatric dental patients.

METHODS

A retrospective chart review of children receiving dental treatments under NOIS between March 2022 and August 2024 was conducted. A sedation session was evaluated as effective when the Overall Houpt Behaviour Rating Scale was greater than or equal to 4 and there were no acute adverse events from NOIS during or within 24 h of sedation. Predictive factors were assessed using the Poisson regression with robust error variance and generalised estimating equations.

RESULTS

A total of 224 sedation sessions from 134 Thai patients aged 3-12 years were included. Of these sessions, 86.2% were considered effective. In the multivariable analysis, previous NOIS experience and the child's preoperative anxiety level were associated with the effectiveness of NOIS. The risk ratio for effective sedation was 13% higher for children with prior NOIS experience compared to those undergoing NOIS for the first time (RR: 1.13, 95% CI 1.02-1.25, p value < 0.05). In addition, the risk ratio for effective sedation in non-anxious children was 41% higher than for extremely anxious children (RR: 1.41, 95% CI 1.07-1.86, p value < 0.05).

CONCLUSION

NOIS is safe and effective for dental treatment in Thai children, with minimal adverse events. Its effectiveness is particularly pronounced in children who have prior experience with NOIS and present as non-anxious.

Equimolar oxygen-nitrous oxide (EMONO) in dental pediatric care: which patients achieve therapeutic effects? A French national exploratory prospective observational multicenter study

PURPOSE

Equimolar oxygen-nitrous oxide mixture (EMONO) is considered as a reference for dental care in children. Completion of dental treatment has usually been used as a criterion to assess EMONO treatment. However, other patient-reported outcomes are needed. We sought to assess the prevalence of complete therapeutic effects (analgesia and anxiolysis) experienced by children during dental care under EMONO and identifying associated factors.

METHODS

A national prospective observational multicentric study was conducted between September 2018 and June 2020 in 13 French university hospitals. Participants were children between 3 and 15 years of age requiring dental care under EMONO.

RESULTS

677 children were analyzed. Anxiolysis and analgesia were experienced by a large majority of patients (86.5% and 79.0%, respectively, and 73% experienced both effects). Several factors were associated with both analgesia and anxiolysis effects: the presence of expected effects (no loss of judgment and slight decrease in level of consciousness), the absence of agitation and distress, a positive perception of EMONO and ethnicity.

CONCLUSION

Most patients benefit from the therapeutic effects (anxiolysis and analgesia) expected by EMONO during dental treatment. It is reassuring to observe that most sociodemographic characteristics and medical history do not seem to influence the effectiveness of care. The study was registered at www.

CLINICALTRIALS

gov under the reference number NCT03453411.

Temperament and past behaviour can predict behaviour success for nitrous oxide sedation

BACKGROUND

There is currently insufficient evidence on potential predictors of a child's behaviour with nitrous oxide (N2O) sedation.

AIM

To examine the association between a child's temperament and behavioural outcomes during dental treatment with N2O sedation, and the child's perception to N2O sedation.

DESIGN

At the first visit (dental treatment visit), temperament was assessed using the Child Behaviour Questionnaire-Short Form and behaviour was assessed by an independent rater using the Venham Behaviour Rating Scale. At the second visit, the child's experience with N2O sedation was elicited.

RESULTS

Seventy-two healthy children aged between 36 and 95 months were recruited. Planned dental treatment was completed in 84.7% of the subjects. Venham behaviour success <3 and Venham behaviour success <1 were achieved in 73.6% and 33.3%, respectively. The temperament domain of effortful control was associated with Venham behaviour score (ρ = -0.266, p = .024) and Venham behaviour success <1 (OR = 3.506, 95% CI = 1.328-9.259, p = .011). Baseline Frankl behaviour score was significantly associated with all behavioural outcomes. Venham behaviour success <3 was significantly associated with a child reporting to have enjoyed the dental treatment visit (p = .026).

CONCLUSION

Effortful control and baseline behaviour were associated with behavioural outcomes of N2O sedation and can be used to predict a child's behaviour.

Horace Wells: A Pioneer in Modern Anesthesia and Pain-Free Medical Practices

Horace Wells, a pioneering figure in the field of anesthesia, was born on January 21, 1815, in Hartford, Vermont. He is widely recognized for his groundbreaking discovery of the anesthetic properties of nitrous oxide, a finding that revolutionized pain management in both medical and dental procedures. Wells' contribution marked a pivotal moment in the history of surgery, transforming it from a traumatic, painful ordeal to a more humane and tolerable practice. Wells initially trained as a dentist and began his career in Hartford, USA, where he developed a reputation for his skill and innovation. His interest in finding a solution to the extreme pain patients experienced during dental work led him to experiment with nitrous oxide, also known as "laughing gas." In 1844, after observing its recreational use, Wells hypothesized that nitrous oxide could be used to alleviate pain during surgical procedures. To test his theory, Wells arranged a public demonstration in which he had his own tooth extracted while under the influence of nitrous oxide. The experiment was a success, proving the anesthetic potential of the gas. Although Wells' initial public demonstration in Boston met with skepticism and failure, his work laid the foundation for the development of anesthesiology. Over time, the medical community recognized the significance of his discovery, which opened the door to further advancements in anesthesia, including the use of ether and chloroform. Wells' contributions, particularly to dental surgery and anesthesia, continue to be celebrated. He is remembered as one of the key figures who helped establish the practice of pain-free surgery, changing the course of both medical and dental fields forever. Despite facing early criticism, Wells' discovery of nitrous oxide remains a cornerstone of modern anesthesia.

Evaluation of children's oral diagnosis and treatment using imaging examination using AI based Internet of Things

BACKGROUND

Although cone beam computed tomography (CBCT) plays an important role in the diagnosis and treatment of oral diseases, its image segmentation method needs to be further improved, and there are still objections about the clinical application effect of general anesthesia (GA) on children's dental fear (CDF).

OBJECTIVE

This study aimed to investigate the application value of CBCT based on intelligent computer segmentation model in oral diagnosis and treatment of children in the context of biomedical signals, and to analyze the alleviating effect of GA on CDF.

METHODS

Based on the regional level set (CV) algorithm, the local binary fitting (LBF) model was introduced to optimize it, and the tooth CBCT image segmentation model CV-LBF was established to compare the segmentation accuracy (SA), maximum symmetric surface distance (MSSD), average symmetric surface distance (ASSD), over segmentation rate (OR), and under segmentation rate (UR) between these model and other algorithms. 82 children with CDF were divided into general anesthesia group (GAG) (n= 38) and controls (n= 44) according to the voluntary principle of their families. Children in GAG were treated with GA and controls with protective fixed intervention. Children's fear survey schedule-dental subscale (CFSS-DS) and Venham scores were counted before intervention in the two groups. CFSS-DS scores were recorded at 2 hours after intervention and after recovery in children in GAG. CFSS-DS and Venham scores were performed in all children 1 week after surgery.

RESULTS

The results showed that the S⁢A value of CV-LBF algorithm was higher than that of region growing algorithm (P< 0.05). OR, UR, MSSD, and ASSD values of CV-LBF algorithm were evidently lower than those of other algorithms (P< 0.05). CFSS-DS scores were lower in GAG than in controls 2 hours after intervention and at return visits after 1 week of intervention (P< 0.001), and Venham scores were lower in GAG than in controls after intervention (P< 0.001). After intervention, the proportion of children with Venham grade 0, 1, 2, and 3 was obviously higher in GAG than in controls (P< 0.001), while the proportion of children with Venham grade 4 and 5 was clearly higher in controls than in GAG (P< 0.001).

CONCLUSION

The results revealed that the computer intelligent segmentation model CV-LBF has potential application value in CBCT image segmentation of children's teeth, and GA can effectively alleviate anxiety of children with CDF and can be used as biomedical signals.

Inhalation anesthesia without any intravenous management for pediatric proton beam therapy

INTRODUCTION

Proton beam therapy is an oncological treatment, argued to be an appropriate tumor irradiation technique for childhood solid tumors. Due to its duration and the need for immobility, many children require anesthesia for proton therapy sessions. As not many centers in the world provide this therapy, there is little published research about pediatric anesthesia for these cases, and the available data suggest a preference for intravenous anesthesia or combined intravenous and inhalation anesthesia. We conducted this study with the aim of describing and analyzing the inhalation anesthetic management of children undergoing proton therapy at our medical center, comparing our results with studies that have followed different anesthetic protocols.

METHODS

We reviewed two major databases (Web of Science and Scopus) to find papers that had addressed, to date, anesthesia for pediatric proton therapy. To describe our anesthetic management, we included all pediatric patients treated with proton therapy under anesthesia in our center between June 2020 and August 2021. The characteristics of the patients, their diagnoses, treatments, airway management, drugs administered, duration of induction, and recovery from anesthesia, and adverse effects where all recorded. All anesthesiologists followed a strict anesthetic protocol based only on inhalational anesthesia with sevoflurane delivered via laryngeal mask airway.

RESULTS

Of the total of 1082 papers found in Web of Science and Scopus on pediatric proton therapy, 11 have addressed its anesthetic management, using intravenous or combined intravenous and inhalation anesthesia. Between June 2020 and August 2021, 31 children were anesthetized in our center to receive proton therapy under inhalational anesthesia (total number of sessions: 873). The mean anesthesia induction time was 4.1 min (SD = 0.7, 95% CI [3.9, 4.4]). The mean anesthesia recovery time was 13.8 min (SD = 4.1, 95% CI [12.3, 15.3]). The percentage of non-serious adverse effects was 0.7% (Clopper-Pearson 95% CI [0.3, 1.5]). The percentage of serious adverse effects was 0.1% (Clopper-Pearson 95% CI [0, 0.6]), without statistically significant difference with other published works with different anesthetic approaches.

CONCLUSION

Inhalation anesthesia without any intravenous management for pediatric proton therapy is, in our experience, an effective technique with a complication rate similar to other anesthetic approaches.

Review of outpatient procedural sedation clinics in a tertiary paediatric hospital in South Australia

AIM

Procedures, such as immunisation and venepuncture, can be distressing for paediatric patients, especially those with needle phobia and neurodevelopmental disorders. Procedural sedation helps provide access to equitable health care in this population. The aim of this study was to evaluate the pilot outpatient procedural sedation clinics at the Women's and Children's Hospital and the impact on patient care and outcomes.

METHODS

A prospective review was undertaken between July 2021 and May 2022 on all patients who attended the procedural sedation clinics at the Women's and Children's Hospital. These clinics were the COVID Specialist Immunisation Sedation Clinic (SISC) and Paediatric Sedation Clinic (PSC).

RESULTS

There were 182 visits in a total of 110 children with a 92% primary procedure success rate. Sixty-three per cent of patients had neurodevelopmental disorders with autism spectrum disorder being most common. There was a significant reduction in anxiety scores pre- and post-sedation and a reduction in anxiety scores if patients were to return without the use of sedation.

CONCLUSIONS

Outpatient procedural sedation is beneficial for a specific cohort of the paediatric population. This can also have a significant positive impact on patient care and potentially, long-term outcomes.

The impact of general medical health status, demographical, and patient-specific variables on need for dental treatment of children and adolescents under general anesthesia

OBJECTIVES

Aim of this retrospective study was to examine the influence of general medical, demographical, and other patient-specific factors on the need for dental treatment under general anesthesia in children and adolescents at Saarland University Hospital. For assessment of the clinical treatment need, a mixed dt/DT (decayed teeth) was introduced.

MATERIALS AND METHODS

A total of 340 patients under 18 years of age who received restorative-surgical dental treatment between 2011 and 2022 were anonymously enrolled. Demographic and other patient-specific data, general medical health, oral health, and treatment related data were recorded. In addition to descriptive analysis, Spearman-Rho-test, Mann-Whitney-U-test, Kruskall-Wallis-test and Chi-square-test were used.

RESULTS

More than half of the patients (52,6%) were in general health, but non-cooperative. The majority of the patients (66.8%) was between 1 and 5 years of age (p < 0,001). Mean dmft was 10.95 ± 4.118, mean DMFT was 10.09 ± 7.885, and mean dt/DT was 10.79 ± 4.273. Analysis showed that communication difficulties significantly influenced dmft (p = 0.004), DMFT (p = 0.019), and dt/DT (p < 0.001). Type of insurance significantly affected dmft (p = 0.004) and dt/DT (p = 0.001). There was no significant effect of ASA on caries experience, however on prevalence of severe gingivitis (p < 0.001), number of extractions (p = 0.002), and need for repeated treatment (p < 0.001).

CONCLUSIONS

Need for dental treatment in the present collective was high, independent of the considered variables. Non-Cooperativeness along with ECC was the main indication for dental general anesthesia. The mixed dt/DT was the most precise survey to evaluate clinical treatment needs.

CLINICAL RELEVANCE

Given the enormous demand for these rehabilitations with strict selection, it is imperative to create more treatment capacities for patients mandatorily requiring general anesthesia by avoiding it in healthy patients.

The Use of Equimolar Mixtures of Nitrous Oxide and Oxygen in Oral Surgery-A Retrospective Study of Patients in a Swiss University Hospital Setting

PURPOSE

The purpose of the study was to evaluate the success of procedural conscious sedation using inhaled equimolar nitrous oxide-oxygen (NOIS-EMONO) in patients undergoing routine dental and oral surgery procedures in a Swiss university hospital setting.

MATERIALS AND METHODS

The authors conducted a retrospective cohort study of patients that underwent NOIS-supported procedures between 2018 and 2022 at the oral surgery department of the University Hospital of Geneva (HUG), Switzerland. The primary outcome was the measurement of the procedure's success and efficacy as defined by the European Society of Anesthesiology. Secondary objectives included the analysis of the types of treatments performed, their indications, patient behavior, and the patient-clinician satisfaction score.

RESULTS

55 patients were included in the study; 85% underwent surgical procedures, and the remaining 15% underwent restorative and preventive procedures. The overall treatment success rate was 98.2% and 97.9% for surgically treated patients. Out of the patients, 62% appeared relaxed, calm, and serene, while 16% expressed pain or fear during the procedure. Infiltrative administration of local anesthesia caused stress in 22% of patients. This portion was significantly lower in sub-cohorts who received local topical anesthetics (0%) or a combination of systemic and local topical analgesics (7%). Patients (75%) and clinicians (91%) were satisfied with the procedure.

CONCLUSION

Inhaled equimolar nitrous oxide-oxygen procedural sedation used during dental procedures and oral surgery results in high treatment success and satisfaction rates. The administration of additional topical anesthetics helps to reduce the anxiety and stress related to infiltrative anesthesia. Further dedicated studies and prospective trials are needed to confirm these findings.

Efficacy of continuous intravenous remimazolam versus midazolam in the extraction of impacted wisdom teeth: protocol of a randomised controlled trial

INTRODUCTION

Benzodiazepines such as midazolam are widely used to moderately sedate patients during impacted wisdom tooth extraction to reduce anxiety in outpatient surgery. This present protocol was designed to determine whether continuous intravenous remimazolam, a new ultrashort-acting benzodiazepine, produces superior postoperative recovery quality to that of midazolam in patients undergoing extraction of impacted wisdom teeth.

METHODS AND ANALYSIS

This study is a multicentre randomised controlled trial conducted at Peking Union Medical College Hospital, Beijing Anzhen Hospital and Beijing Shijitan Hospital in China. Approximately 150 participants undergoing extraction of impacted mandibular wisdom teeth will be randomly allocated to two groups (remimazolam and midazolam). The participants will be administered standard interventions to ensure they achieve a sedation level of III on the Ramsay sedation scale during the treatment. Preoperative and anaesthesia management and surgical techniques will be standardised for all participants. The primary outcome is recovery time for complete alertness and the secondary outcomes are anterograde amnesia during and after surgery, and interruption during operation for poor compliance or safety concerns.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Review Committee of Peking Union Medical College Hospital (approval number: ZS-3142), Beijing Anzhen Hospital (approval number: KS2022082) and Beijing Shijitan Hospital (approval number: 2023-4).

TRIAL REGISTRATION NUMBER

NCT05350085.

Behavioral Modifications in Children after Repeated Sedation with Nitrous Oxide for Dental Treatment: A Retrospective Study

Sedation with nitrous oxide (N₂O) has been widely used as a viable alternative to general anesthesia to perform dental treatments in uncooperative or anxious children. The purpose of this retrospective study is to assess if repeated sedations with N₂O can improve collaboration of uncooperative children. The medical records of 650 children, aged between 3 and 14 years, who underwent at least two sedations, were consulted. Differences in the Venham score during the first sedation and subsequent sedations were collected. After removal incomplete records, 577 children's records (309 males and 268 females) were analyzed. The Venham score decreased both during each sedation and with repeated sedations (p < 0.01 for both comparisons). In particular, a significant reduction of the Venham score was observed at the first contact with the dentist, with a mean score ranging from 1.56 ± 1.46 to 1.16 ± 1.37, comparing the first and the second sedation, and from 1.65 ± 1.43 to 1.06 ± 1.30, comparing the first with the third sedation (p < 0.01). The reduction in the Venham score was recorded in both healthy and physically impaired patients, and it was significantly greater in older children than in younger children (p < 0.01). In conclusion, uncooperative children with or without physical impairments can be successfully treated with N₂O sedation in order to increase their confidence in dental procedures.

Conscious Sedation for Dental Treatments in Subjects with Intellectual Disability: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis was aimed to investigate the conscious sedation efficiency in patients with intellectual disability undergoing dental treatment (PROSPERO CRD42022344292). Four scientific databases were searched by ad-hoc prepared strings. The literature search yielded 731 papers: 426 were selected, 42 were obtained in full-text format, and 4 more were added after hand searching. Fourteen studies were finally included, 11 of which were included in the meta-analysis (random effect model). A high heterogeneity in the drugs used and route of administration was retrieved. Success rate, occurrence of side effects, and deep sedation occurrence were combined to give an overall efficiency of each drug. N2O/O2 reported the highest efficiency (effect size = 0.90; p < 0.01) and proved to be more efficient when used alone. Nine papers reported a success rate of sedation of 80% or more. The prevalence of side effects (6 studies) ranged from 3% to 40%. Enteral and parenteral benzodiazepines showed the same overall efficiency (effect size = 0.86). No meta-analysis has yet been conducted to define the most effective and safest way to achieve conscious sedation in patients with intellectual disability; nitrous oxide appears to be the best choice to perform conscious sedation in patients with intellectual disability undergoing dental treatment.

Comparison of quality of life measures and post-operative anxiety in children undergoing treatment under general anesthesia and nitrous-oxide sedation

Objective: To compare quality of life measures and post-operative anxiety in children undergoing treatment under General anesthesia and Nitrous-oxide sedation. Study design: 70 unco-operative children aged 3-5 years received full mouth rehabilitation treatment either under general anesthesia or nitrous oxide sedation. The physical as well as the social quality of life measures was evaluated using questionnaire given to parents at 1 week, 6 months and 12 months post-operatively. The child’s fear and anxiety was evaluated post-operatively for both the groups using CFSS-DS scale. Statistically analysis for comparison between the two groups was carried using Wilcoxon signed ranked test. Result: There is no difference in the physical quality of life as well as social quality of life measures between treatment under general anesthesia and nitrous oxide sedation at 1 week, 6 months and 12 months post-operatively (P>0.05). Children treated under nitrous oxide sedation show decreased fear and anxiety post-operatively as compared to children treated under general anesthesia. (P<0.05) Conclusion: Treatment under general anesthesia and nitrous oxide sedation shows similar improvement in post-operative physical as well as social quality of life. There is a decrease in the dental fear and anxiety post-operatively after treatment under nitrous oxide sedation

Assessment of Effectiveness Acceptability Complications and Parental Satisfaction of Pediatric Dental Patients Treated under Nitrous Oxide-oxygen Inhalational Sedation Using Porter Silhouette Mask

Objectives

To estimate the concentration of nitrous oxide (N2O) required for effective sedation to render dental treatment for an anxious child and to assess the child's behavior, patient acceptance, parental satisfaction, postoperative complications, and ease of manipulation of Porter Silhouette mask by the dentist during N2O-O2 sedation.

Study design

A total of 40 children, 6-10-year-old requiring dental treatment, were treated using N2O sedation. The level of N2O required for optimal sedation, patient behavior, level of acceptance of N2O by the patient, clinical recovery score, and postoperative complications were observed throughout the study. At the end of the treatment, a questionnaire was given to the parents to evaluate parental satisfaction.

Results

The sedation was very effective, with 25-50% of N2O concentration. About 92.5% of children were fully cooperative, the dentist was able to place the mask with comfort in 92.5% of children, significant improvement was seen in the patient's behavior with minimal complications, and 100% of the parents were satisfied with the treatment under sedation.

Conclusion

Inhalational sedation with N2O using Porter Silhouette mask results in effective sedation, with increased patient comfort, and parental acceptance in providing dental treatment.

How to cite this article

AKR SP, Mungara J, Vijayakumar P, et al. Assessment of Effectiveness Acceptability Complications and Parental Satisfaction of Pediatric Dental Patients Treated under Nitrous Oxide-oxygen Inhalational Sedation Using Porter Silhouette Mask. Int J Clin Pediatr Dent 2022;15(5):493-498.

Case Report: Applicability of sedation with nitrous oxide in the management of molar incisor hypomineralization in pediatric patients

Patients with molar-incisor hypomineralization (MIH) may manifest tooth hfypersensitivity and difficulties in undergoing dental treatment, including fear, anxiety, and behavior problems in the dental office. Then, the objective of this study was to report a clinical case series using inhalation sedation with nitrous oxide and oxygen as a clinical strategy in the management of MIH pediatric patients during dental treatment. Pediatric patients and their legal guardians were properly informed and data were extracted from clinical charts. Six clinical cases were included, whose patients were between 8 and 12 years old. Of these, 4 were female. The indication of moderate sedation took into account the clinical difficulties related to patients with MIH, such as obtaining anesthesia and cooperation, in addition to odontophobia and dental anxiety. All patients were carefully examined to undergo the sedation technique, including medical history and previous experiences with nitrous oxide inhalation sedation, as well as the vital signs were properly evaluated before, during and after the procedures. The nitrous oxide concentration ranged between 30% and 60%. The procedures were restorative, endodontic or surgical (extractions). In general, the use of sedation contributed to the performance of dental procedures. The use of inhaled sedation helped in behavioral management and during the treatment, increasing the effectiveness of local anesthesia. Patients were cooperative for treatment, while no adverse effects or complications related to sedation were observed. Thus, for the patients in this case series, the use of inhalation sedation with nitrous oxide and oxygen contributed to the clinical management of patients with MIH.

An Observational Retrospective Study of Adverse Events and Behavioral Outcomes During Pediatric Dental Sedation

Purpose: The purpose of this study was to examine a university-based dental electronic health records (EHR) database to identify sedation-related adverse events (AEs) and assess patients' behavioral outcomes during routine pediatric dental sedations (PDSs) in a dental school clinic. Methods: A database was screened for patients younger than 18 years old who had received dental sedation in 2019. The qualifying EHRs were then accessed and sedations were reviewed for AEs, which were categorized using a 12-point classification system and the Tracking and Reporting Outcomes of Procedural Sedation Tool. Patient behaviors were assessed using provider progress notes and categorized as presence/ absence of agitation. Results: A total of 690 sedations were reviewed, yielding 28 AEs. Emesis was the most common AE observed in 1.3 percent of sedations. Respiratory and cardiovascular AEs were observed in 0.7 percent and 0.6 percent of sedations, respectively. Agitation was identified in 47.5 percent of sedations, while 34.1 percent of agitations resulted in the documented suspension of dental treatment. Agitation was mainly observed for nitrous oxide and oral sedation resulting in one failed sedation out of five sedations for each method. Conclusions: Potentially serious adverse effects were identified during pediatric dental sedations, but their incidence was low. A significant proportion of the sedated children experienced agitation, resulting in some sedation failures. Such events need to be tracked and examined for risk assessment reduction and quality-of-care improvement.

The relationship between nitrous oxide sedation and psychosocial factors in the pediatric outpatient setting

BACKGROUND

Moderate sedation using nitrous oxide (N₂ O) has become common in pediatric dentistry. However, less is known regarding the role of patients' characteristics and psychosocial factors in their cooperative behavior during dental procedures with N₂ O.

AIMS

This study aimed to examine pediatric dental patients' behaviors while undergoing N₂ O sedation and to measure the associations between child's cooperative behavior and demographic, physiological responses, and psychosocial factors.

METHODS

In this within-subject observational study, participants received 40% N₂ O/O₂ , by nasal hood, for non-surgical dental procedures. The main outcome measure was the extent of cooperative behaviors, as assessed by the Frankl scale at five timepoints, namely T1: pre-administration of N₂ O, T2: post-administration of N₂ O, T3: dental injection, T4: dental treatment, and T5: post-procedure administration of 100% O₂ . Predictors included age, sex, psychosocial factors reported using the Parenting Style and Dimension Questionnaire and Spence Children Anxiety Scale, as well as pulse rate, respiratory rate, and oxygen saturation. The Wilcoxon signed-rank test and generalized estimation equation were used for data analyses.

RESULTS

In 80 children with a mean age of 7.2 (2.2) years, administration of N₂ O was significantly associated with cooperative behaviors (odds ratio [OR]:2.62, confidence interval [CI]: 1.46-4.70, p = .001) when adjusted for other predictors. There was no interaction between any of the predictors and N₂ O sedation on behaviors. Except for the authoritative parenting style (OR: 1.96, CI: 1.16-3.31, p = .012), which predicted more cooperative behaviors, other predictors were not associated with behavioral outcomes.

CONCLUSION

In children sedated with N₂ O, behavior was independent of the child's demographic and psychosocial factors. While sedated, demographics, vital signs, and anxiety did not contribute to behavior management. However, screening for parenting style may help predict the child's behavioral response.

Conscious Sedation in Dentistry for the Management of Pediatric Patients with Autism: A Narrative Review of the Literature

(1) Background: the variety of autism spectrum disorder makes the definition of guidelines for dental care a challenging task. The aim of this review was to evaluate the literature concerning the use of conscious sedation for dental treatments in pediatric autistic patients. (2) Methods: we searched MEDLINE/PubMed, EMBASE, Cochrane databases in order to identify pertinent studies. The search strategy was based on these areas of interest: autistic spectrum disorder, pediatric patients, dentistry, tranquilizing agents, and conscious sedation. (3) Results: the search yielded 177 non-duplicated articles, of which 24 articles were retrieved for full text review, and 2 were found to address our review aim. The first paper was a retrospective study that included 83 autistic patients sedated either with an oral premedication combined with nitrous oxide/oxygen inhalation or with nitrous oxide/oxygen inhalation alone; the second article was a prospective trial on the effectiveness of 0.3 mg/kg of oral diazepam with 0.5 mg/kg of oral midazolam in 13 sedated uncooperative autistic patients. (4) Conclusions: this review highlights the insufficiency of studies that can provide concrete indications for the dental treatment in conscious sedation of pediatric patients with autism. New studies are needed to better define the appropriate drugs, dosages, sedation level and evaluate patient cooperation.

Success rate of nitrous oxide-oxygen procedural sedation in dental patients: systematic review and meta-analysis

The aim of this systematic review was to determine the success rate of nitrous oxide-oxygen procedural sedation (NOIS) in dentistry. A systematic digital search was conducted for publications or reports of randomized controlled trials evaluating the clinical performance of NOIS. Abstracts of research papers were screened for suitability, and full-text articles were obtained for those who met the inclusion and exclusion criteria accordingly. The quality of the studies was assessed using the revised Cochrane risk-of-bias tool (RoB 2). A total of 19 articles (eight randomized clinical trials with parallel intervention groups and 11 crossover trials), published between May 1988 and August 2019, were finally selected for this review. The studies followed 1293 patients reporting NOIS success rates, with a cumulative mean value of 94.9% (95% CI: 88.8–98.9%). Thirteen trials were conducted on pediatric populations (1098 patients), and the remaining six were conducted on adults (195 patients), with cumulative efficacy rates of 91.9% (95% CI: 82.5–98.1%) and 99.9% (95% CI: 97.7–100.0%), respectively. The difference was statistically significant (P = 0.002). Completion of treatment and Section IV of the Houpt scale were the most used efficacy criteria. Within the limitations of this systematic review, the present study provides important information on the efficacy rate of NOIS. However, further well-designed and well-documented clinical trials are required and there is a need to develop guidelines for standardization of criteria and definition of success in procedural sedation. Currently, completion of treatment is the most used parameter in clinical practice, though many others also do exist at the same time. To maximize NOIS efficacy, clinicians should strictly consider appropriate indications for the procedure.

Pain Experienced during Various Dental Procedures: Clinical Trial Comparing the Use of Traditional Syringes with the Controlled-Flow Delivery Dentapen® Technique

Background and Objectives: Currently, one of the most discouraging aspects for many patients undergoing dental procedures is the administration of anaesthesia. Consequently, there is a constant search for new techniques to avoid the invasive and painful nature of the injection. A new motorised syringe system (Dentapen^®) has recently been developed, standing out for its convenience and ease of use. Material and Methods: Randomised, controlled, single-blind, and single-centre study including 178 voluntary adult participants aged between 18 and 90 years. Individuals were randomly assigned using a randomised table. Patients were asked to rate the level of pain experienced during the injections, using a 10-point visual analogue scale (VAS). The following data were recorded: pain index, heart rate, blood pressure, and saturation, both before and after anaesthesia. Results: Of the total 178 participants, 87 participants (48.9%) were men and 91 (51.1%) were women. The first variable to be assessed was the pain experienced by patients when anaesthetised with a syringe, obtaining a mean value of 2.63 ± 1.86 on the VAS with the conventional syringe and 1.06 ± 1.28 with the Dentapen^® syringe, showing statistically significant differences (p-value < 0.01). When stratifying, based on the procedure that was undertaken, differences were also significant for all treatments (p-value < 0.01) except for endodontics, where differences were likely to be significant (p-value = 0.02). Conclusions: In conclusion, from a clinical standpoint, the Dentapen^® syringe is a valid alternative to traditional infiltration syringes, causing minimum pain with the injection.

Effectiveness and Safety of Intravenous Sedation with Propofol in Non-Operating Room Anesthesia (NORA) for Dental Treatment in Uncooperative Paediatric Patients

Background: Uncooperative children require sedative approach for dental treatment. The aim was to assess the effectiveness of Propofol in “Non-Operating Room Anesthesia” (NORA) for paediatric dental treatment; intraoperative side effects; postoperative side effects; post-discharge effects. Methods: a prospective study, involving 109 uncooperative children undergoing sedation in NORA using Propofol for dental treatment, was performed. Working sessions, success/failure, intraoperative and postoperative side effects, number of treatment; type of procedure were assessed. Parents completed a post-discharge questionnaire on: pain; crying; fever; vomiting; headache; drowsiness; excitability; irritability; ability to eat; drugs and medical care needing. Results: Success: 96.7%. Intraoperative side effects: 33.3%. Postoperative side effects: 6.4%. Statistically significant association between: intraoperative side effects and age (p = 0.001), health status (p = 0.0007), weight (p = 0.038), respectively; intraoperative side effects and number/ type of dental treatment (p = 0.0055) and scaling (p = 0.0001), respectively. For post-discharge questionnaires, statistically significant association between: age and crying (p = 0.0001) and headache (p = 0.002), respectively; health status and crying (p = 0.015) and drugs needing (p = 0.04), respectively; weight and crying (p = 0.0004); extraction and pain (p = 0.0001) and crying (p= 0.0073), respectively; scaling and crying (p = 0.04), excitability and irritability (p = 0.03), respectively. Conclusion: Propofol in NORA was effective with minimal side effects.

The Effect of Transcutaneous Electric Nerve Stimulation (TENS) on Anxiety and Fear in Children Aged 9-14 Years

Introduction

Dental fear or dental phobia is caused by previous unpleasant dental experiences and pain. It can result in delaying or avoiding dental visits. Most often it leads to individuals avoiding visiting the dentist until physical pain completely impairs the quality of life.

Objectives

Transcutaneous electrical nerve stimulation (TENS) is a method of pain relief involving the use of a mild electrical current. The main aim of this study was to examine whether the TENS device affects the reduction of anxiety and fear during dental procedures.

Material and Methods

The study was conducted on a sample of 125 respondents, aged 9-14 years. Statistical significance of differences between pre- and post-treatment results on all applied measuring instruments was verified by the t-test for dependent samples. The calculation was performed for all respondents and individually for the three observed groups. The Children`s Fear Survey Schedule – Dental Subscale test was used to assess anxiety and fear.

Results

The results on the CFSS-DS scale in all subjects did not differ statistically significantly before and after treatment (p > 0.05). The results on the CFSS-DS scale in subjects who received TENS were statistically significantly different before and after treatment (p < 0.01). The results on the CFSS-DS scale in subjects who received local anesthesia were statistically significantly different before and after treatment (p < 0.05).

Conclusion

The TENS device had an anxiolytic effect after the first visit.

Child behaviour during dental care under nitrous oxide sedation: a cohort study using two different gas distribution systems

Purpose

Conscious sedation by inhalation of a mixture of nitrous oxide and oxygen (CS) is a technique used in dental care for anxious, handicapped or uncooperative patients. The very special objective of this cohort study is to compare the behaviour of young patients during dental care under CS in two hospitals using different gas distribution systems.

Methods

Young patients were divided into four categories: young child (YC), phobic anxiety (PA), mental disorder (MD), occasional indication (OI). Differences in behaviour scale at various time points according to the sedation system used were established and compared using Mann–Whitney tests.

Results

This study showed that there is no difference in behaviour during dental care in YC after sedation. In PA, a significant difference in behaviour is only observed during local anaesthesia (p = 0.024).

Conclusion

No significant differences detected in children’s behaviour under conscious sedation using different gas administration systems. The delicate stage of local anaesthesia in PA patients can be facilitated with repeated sessions of dental care under conscious sedation.

Electronic supplementary material

The online version of this article (10.1007/s40368-020-00569-z) contains supplementary material, which is available to authorised users.

A case series analysing patients with dental anxiety: a patient-centered model based on psychological profiling

Anxiety and distress can jeopardize dental care experience of patients and may affect the clinical result. Although a wide range of sedation and analgesia techniques are currently available to relieve distress and pain during dental procedures, operative models to choose the most effective sedation-analgesic strategies are still insufficient.

This case series proposes a patient-centered model to optimize patients’ cooperation during dental care delivery. We describe how to achieve correct anaesthesia by using the least sedative procedure, accounting for the dental procedure needed and patient’s psychological profile.

Five patients were considered as paradigmatic to show the balance between patients’ subjective experiences and the clinical procedures: a patient with low stress, good compliance (case 1); a patient with moderate stress and reduction in compliance (case 2); anxious patient (case 3); a patient with acute anxiety and emotional distress (case 4); anguished patient (case 5).

A multimodal treatment of emotional and behavioural condition and a patient-centered model approach contributed to achieve the best patient satisfaction in the five cases detailed here.

Post-operative discomforts in children after extraction of primary teeth

Objectives

This prospective observational study aimed to evaluate discomfort after extraction of deciduous teeth under local anesthesia. The primary objective was to describe the prevalence of post‐extraction pain (PEP), post‐extraction bleeding (PEB), post‐extraction biting injury (PEBI), and analgesic usage in children. The secondary objective was to define whether it is possible to determine a profile of patients or a type of extraction procedure predictive to PEP, administration of analgesics, PEB, or PEBI.

Methods

One hundred and twenty‐five children, aged 3–13 years, with indications of at least one deciduous tooth extraction, were included. Immediately after extraction, information concerning the patient and the extraction were collected. Eighteen to 32 hr after extraction, parents were called by phone to request reports concerning the onset and intensity of PEP assessed using the Wong‐Baker Faces (WBF) scale, the administration of paracetamol (acetaminophen) to their children, and the appearance of PEB and/or PEBI.

Results

Of the children, 37.3% reported PEP (WBF ≥2), but 23.3% of these children did not receive any analgesic drugs to help relieve pain. Pain appeared before 3 hr after extraction in 69% of the children. Higher incidences of PEP and usage of analgesics were found both in the group of children with unfavorable socioeconomic level compared to favorable level and in the group with pre‐operative pain compared to no pre‐operative pain (p < .05).

Conclusions

About a third of the children reported pain after extraction, but the instructions for pain relief were not followed by all parents. The socioeconomic level of the young patient and the pain felt during the extraction were important predictors of discomfort. Therefore, our study could help the dentist to provide information on predicted post‐operative discomfort and to allow suitable care depending on the patient's profile or procedure.

Impact of Opioid Analgesia and Inhalation Sedation Kalinox on Pain and Radial Artery Spasm during Transradial Coronary Angiography

With respect to the transfemoral approach, transradial procedures enable a drastic reduction of bleeding events and are associated with a reduction of mortality. Radial artery spasm (RAS) is one of the most common complications and may lead to patient discomfort and procedural failure. Currently, there is no consensus on the optimal sedation protocol to avoid RAS. The aim of this study was to investigate the respective impact of opioids analgesia and inhalation sedation with a 50% nitrous oxide/oxygen premix (Kalinox) on pain and occurrence of RAS during transradial coronary procedures. Consecutive patients undergoing transradial coronary angiography were prospectively enrolled in one, single center observational study (Nouvel Hôpital Civil, Strasbourg, France). Patients received opioids analgesia or inhalation sedation with Kalinox. The primary endpoints of the study were the incidence of a pain scale ≥5/10 and the occurrence of RAS. The secondary endpoints were the incidence of side effects. A total of 325 patients were enrolled (185 in the opioids analgesia group, 140 in the Kalinox group). RAS and pain scale ≥5 rates were not significantly different in the opioids analgesia and Kalinox groups (respectively 13.5% vs. 10.0% and 16.2% vs. 11.4%). Headache was more frequently observed in the Kalinox group (6.4% vs. 0.0%; p = 0.002). By multivariate analysis, female gender, BMI <25 kg/m², puncture difficulty, the use of plastic needle and 6F sheath were identified as independent predictors of RAS. Procedural inhalation sedation by Kalinox is as safe as opioids analgesia during transradial coronary angiography.

The Effect of Dental Treatment under General Anesthesia on Quality of Life and Growth and Blood Chemistry Parameters in Uncooperative Pediatric Patients with Compromised Oral Health: A Pilot Study

BACKGROUND

The effect of untreated dental caries and their treatment under general anesthesia (GA) on the quality of life, growth, and blood chemistry parameters in uncooperative pediatric patients has not been extensively elucidated. The aims are to evaluate the impact of dental treatment under GA on oral health-related quality of life (OHRQoL) in uncooperative pediatric patients with severe dental caries and to assess the effect of dental treatment under GA on children's weight (Wt), height (Ht), Body Mass Index (BMI), and blood chemistry parameters.

METHODS

Forty-three uncooperative children aged 3-14 years were selected. OHRQoL, through ECOHIS (Early Childhood Oral Health Impact Scale) and COHRQoL (Child Oral Health-Related Quality of Life) questionnaires, Wt, Ht, BMI, and blood chemistry parameters were measured at baseline and eight months after dental treatment under GA.

RESULTS

At follow up, the reductions in the ECHOIS and the COHRQoL components were statistically significant (p < 0.0001), there was significant improvement in the anthropometric measures: 76.5% of children increased the percentile curves for weight, 68.6% for height, and 51.4% for BMI; for the blood chemistry parameters: ferritin improved in 68.6% of the samples, PCR in 65.7%, ESR in 68.6%, Vitamin D in 68.6%, and IGF-1 in 65.7%.

CONCLUSIONS

Oral health status significantly influences OHRQoL, growth, and blood chemistry parameters in uncooperative pediatric patients.

Evaluation of general anesthesia and sedation during dental treatment in patients with special needs: A retrospective study

Background

Patients with special health care needs are more likely to develop health problems, including dental problems. Dental treatments require a good level of communication with the patient. Therefore, in these patients, sedation and general anesthesia are an extremely humanistic approach for comfortable and successful treatment. In patients with special needs, there is no standard anesthetic approach due to varying clinical conditions. The aim of this study was to provide literature content about the anesthetic approaches used by us in patients with special needs.

Methods

The medical records of 710 patients with special health care needs treated under general anesthesia or sedation were reviewed retrospectively. Demographic data, the American Society of Anesthesiologists classification, Mallampati score, anesthesia duration, anesthesia type, anesthetic and analgesic agents used, dental treatment performed, secondary diseases, and complications in the perioperative period were recorded. Patients were evaluated under five groups: Down syndrome, other syndromes, psychiatric disorders, physical disabilities, and complicated medical story.

Results

Among the patients evaluated, 47.5% were females and 52.5% were males (mean age 15.76 ± 11.17 years), and general anesthesia and sedation were administered in 72.9% and 22.1% patients, respectively. The mean duration of anesthesia was 43.20 ± 35.85 min. Simple dental treatments were performed in all groups, and the most common complications were observed in the other syndromes group.

Conclusion

Complications can be reduced by utilizing the appropriate anesthetic approach and taking serious precautions in patients with special needs.

The pearls of pediatric sedation: polish the old and embrace the new

Over the past decade, as the complexity and breadth of pediatric procedures increases, the actual choices of approved sedatives have remained relatively stagnant. Since the introduction of midazolam, there has not been a sedative approved for pediatric labelling until December 2018. This December, the European approval of ADV6209 (Ozalin) for pediatric usage marked the newest addition to the pediatric sedative armamentarium in over a decade. This review is timely and significant because it will provide a balanced evaluation of the most common sedatives in use today, the most recent sedative to be approved and, most importantly, a critical look at the literature supporting the latest approaches to the most commonly performed procedures.

Management of carious primary molars within the community dental setting in Wales: a retrospective observational study

Background Tertiary prevention is still an integral part of a child's healthcare. In community dental service (CDS), we aim to try to restore carious primary teeth in young children as a means of caries control.Aim To assess the survival rates of individual carious primary molars within CDS, based on the type of dental interventions.Design Retrospective observational study.Methods Fifty patients' notes were reviewed, and patients were selected using a defined protocol. The Kaplan-Meier method was used to estimate the survival curves.Results Out of 251 teeth, the estimated survival rates of teeth restored with stainless steel crowns (SSC) was the highest at 46.7 months, GIC-restored teeth at 45.8 months and unrestored teeth at 18.2 months. There was no correlation seen between the survival rates and the number of further interventions required. The difference between the survival rates of teeth restored with GIC, SSC and unrestored was statistically significant (p <0.05). There was minimal use of SSCs within this sample.Conclusion Our present findings indicate that restored teeth have higher survival rates than unrestored teeth. However, it must be emphasised that restorative treatment may not always be feasible and other factors should be considered in the treatment planning.

Nitrous oxide occupational exposure in conscious sedation procedures in dental ambulatories: a pilot retrospective observational study in an Italian pediatric hospital

BACKGROUND

Nitrous oxide has a proven clinical efficacy in conscious sedation. At certain environmental concentrations it may pose a health risk to chronically exposed healthcare workers. The present pilot study aims at evaluating the exposure to nitrous oxide of dental ambulatory personnel of a pediatric hospital.

METHODS

A descriptive study design was conducted in two phases: a bibliographic analysis on the environmental safety policies and a gas concentration analysis in the dental ambulatories of a pediatric hospital, detected every 6 months from December 2013 to February 2017 according to law provisions. The surveys were carried out using for gas analysis a photoacoustic spectrometer Innova-B&K "Multi-gas monitor model 1312" and Innova-B&K "Multi-sampler model 1309". The biological analysis and monitoring have been carried out on staff urine.

RESULTS

The analyses were performed during 11 dental outpatient sessions on pediatric patients. All the patients were submitted to the same dental procedures, conservative care and dental extractions. The pediatric patients were 47 (23 males, 24 females; age range 3-17 years; mean age 6,63, SD ± 2,69) for a mean of 4,27 (SD ± 1,49) per session., The mean environmental concentration of nitrous oxide during the sessions was 24.7 ppm (SD ±16,16). A correlation was found between urinary nitrous oxide concentration of dentists (Pearson's correlation 0.786; p = 0.007) and dental assistants urines (Pearson's correlation 0.918; p < 0.001) and environmental concentrations of nitrous oxide. Weak negative correlations were found between age and sex of patients and environmental concentrations of nitrous oxide. The mean values of the biological monitoring data referring to all the outpatient sessions are lower than the reference values foreseen in accordance to the regulations in force on nitrous oxide concentration.

CONCLUSIONS

The mean environmental concentration values recorded in our study are below the limit of 50 ppm considered as a reference point, a value lower than those reported in other similar surveys. The results of the present study provide a contribution to the need to implement technical standards, criteria and system requirements for the dental ambulatories, to date not yet completely defined, and cannot be assimilated to the ones established for the surgical rooms.

Which factors most influence referral for restorative dental treatment under sedation and general anaesthesia in children with complex disabilities: caries severity, child functioning, or dental service organisation?

BACKGROUND

The UN Convention on the Rights of the Child gives all children right to the highest standard of services for treatment and rehabilitation. For children with disabilities, sedation and general anaesthesia (GA) are often indicated for dental treatment; however, accessibility to this varies. The International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) enables a biopsychosocial description of children undergoing dental treatment.

AIM

To investigate conscious sedation and GA in children with complex disabilities and manifest caries and analyse how caries, child functioning, and dental service organisation relate to dental GA (DGA), comparing Argentina, France, and Sweden using the ICF-CY.

DESIGN

Quantitative, cross-sectional; data collected through structured interviews, observation, and dental records.

RESULTS

Sedation and DGA were common. Children with limitations in interpersonal interactions and relationships were more likely to have had DGA (OR: 5.3, P = 0.015). Level of caries experience was strongly correlated with experience of DGA. There were significant differences between countries regarding caries prevalence, sedation, DGA, and functional and environmental factors.

CONCLUSIONS

Although caries experience and child functioning are important, dental health service organisation had the most impact on the incidence of DGA, and for the use of conscious sedation, for children with complex disabilities.

Conscious Sedation in Dentistry

Sedation in dentistry has been a controversial topic due to questions being raised over its safety, especially in dental chair. Dental fear and anxiety are not only common in children but also significantly prevalent among adults due to high intensity of pain. Sharing of airway between the anesthesiologist and the dentist remains the greatest challenge. The purpose of this review is to study the recent trends in conscious sedation in the field of dentistry from an anesthesiologist's perspective. It will provide a practical outline of the pharmacokinetics, pharmacodynamics, and routes of administration of the drugs or gases used.

Pain Experience and Behavior Management in Pediatric Dentistry: A Comparison between Traditional Local Anesthesia and the Wand Computerized Delivery System

Aim. To evaluate the pain experience and behavior during dental injection, using the Wand computerized delivery system versus conventional local anesthesia in children and adolescents. Methods. An observational crossover split mouth study was performed on 67 patients (aged 7 to 15 years), requiring local anesthesia for dental treatments in both sides of the dental arch. Patients received both types of injections in two separate appointments, one with the use of a Computer Delivery System (the Wand STA system) and one with the traditional syringe. The following data were recorded: pain rating; changes in heart rate; level of collaboration; patient satisfaction. The data were analyzed using ANOVA for quantitative outcomes and nonparametric analysis (Kruskal–Wallis) for qualitative parameters. Results. The use of the Wand system determined significantly lower pain ratings and lower increase of heart rate than the traditional syringe. During injection, the number of patients showing a relaxed behavior was higher with the Wand than with the traditional local anesthesia. The patient level of satisfaction was higher with the Wand compared to the conventional local anesthesia. Conclusions. The Wand system may provide a less painful injection when compared to the conventional local anesthesia and it seemed to be better tolerated with respect to a traditional syringe.