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  • 1.
    Johansson, Kristina
    et al.
    Malmö University, Faculty of Odontology (OD). Department of Orthodontics, Östersund Hospital, Östersund, Sweden.
    Bokander Matilainen, Linda
    Malmö University, Faculty of Odontology (OD).
    Wiaderny, Michal
    Department of Orthodontics, Folktandvården Dalarna, Falun, Sweden.
    Berlin, Henrik
    Malmö University, Faculty of Odontology (OD).
    Klingberg, Gunilla
    Malmö University, Faculty of Odontology (OD).
    Ghiasi, Houda
    Private Orthodontic Practice, Bernhold Ortodonti, Helsingborg, Sweden.
    Brechter, Anna
    Private Orthodontic Practice, Bernhold Ortodonti, Helsingborg, Sweden.
    Paulsson, Liselotte
    Malmö University, Faculty of Odontology (OD).
    Self-reported pain during different phases of orthodontic treatment with fixed appliance: A multi-centre randomized controlled trial in adolescents with crowding2024In: Orthodontics & craniofacial research, ISSN 1601-6335, E-ISSN 1601-6343Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To compare self-reported pain levels across various treatment phases using passive self-ligating (Damon) and conventional (Victory) standardized fixed appliance systems.

    MATERIALS AND METHODS: Adolescents (12-17 years old) with crowding and displaced teeth, planned for non-extraction treatment, were recruited from four orthodontic clinics. They were randomized into stratified blocks (1:1 ratio) using concealed allocation to receive Damon Q™ (34 boys, 28 girls) or Victory™ (39 boys, 31 girls). Pain and analgesic intake were assessed on seven different occasions with validated self-report questionnaires using a 10-grade scale.

    RESULTS: Of the 132 patients included, six were lost to follow up. Clinically relevant mean pain scores (≥4) were registered in both groups after bonding upper and lower arches and after insertion of 0.019 × 0.025 stainless steel archwire. The highest mean scores were reported on day two after bonding the upper arch (Damon 5.96, Victory 7.18, P = .011). In both groups, at least 40% reported taking analgesics during various treatment phases. The Damon group reported a lower intake of analgesics on days one and two (P = .042 and .037) after treatment initiation. In the entire sample, boys reported significantly higher mean pain scores than girls on the second and third days after bonding (P = .008 and .026, respectively).

    CONCLUSIONS: Lower pain levels were reported from the Damon group after bonding. In general, boys reported higher pain than girls did. Clinicians and adolescents need to be aware that clinically relevant pain levels can be expected not only after bonding but also in later phases.

  • 2.
    Roxner, Rikard
    et al.
    Malmö University, Faculty of Odontology (OD).
    Hallberg, Ulrika
    Malmö University, Faculty of Odontology (OD).
    Berlin, Henrik
    Malmö University, Faculty of Odontology (OD).
    Klingberg, Gunilla
    Malmö University, Faculty of Odontology (OD).
    Undergraduate dental students' perceptions of dental pain in children - A grounded theory study.2024In: European journal of dental education, ISSN 1396-5883, E-ISSN 1600-0579Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: There is an underuse of pain management strategies in dental care for children, possibly owing to perceived stress and discomfort when treating children, which has also been reported by dental students. The aim of this study was to explore how undergraduate dental students experience and understand pain related to dental treatment in children.

    MATERIALS AND METHODS: Interviews were held with 21 Swedish dental students, from 3 dental schools, all in their final 2 years of education. The interviews were transcribed verbatim and analysed according to Grounded Theory.

    RESULTS: A core category, seeking guidance to avoid pain, was identified and related to 6 conceptual categories. The students used different strategies to manage pain prevention in child dentistry and to become skilled dentists. They described high levels of stress, as well as having high expectations on themselves when treating children. The stress led to a surface learning approach, something the students were not fully aware of.

    CONCLUSION: All children should have the right to be ensured optimal pain prevention in dental care. The basis for this is laid during undergraduate education. Thus, pain management in child dentistry is an area in need of special attention in this respect. The academic staff has an important role in supporting their students in their process to gain an identity as professional dentists. To ensure that students incorporate an understanding of the importance of pain prevention when treating children there is a need to create more integration between theory and clinical training in undergraduate education.

  • 3.
    Berlin, Henrik
    et al.
    Malmö University, Faculty of Odontology (OD).
    Hallberg, Ulrika
    Malmö University, Faculty of Odontology (OD).
    Ridell, Karin
    Malmö University, Faculty of Odontology (OD).
    Toft, Danijela
    Colosseum Smile Dental Group, Malmö, Sweden.
    Klingberg, Gunilla
    Malmö University, Faculty of Odontology (OD).
    A grounded theory study on Swedish 10 to 16-year-olds’ perceptions of pain in conjunction with orthodontically indicated tooth extraction2023In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 81, no 3, p. 235-240Article in journal (Refereed)
    Abstract [en]

    Objective: Children frequently experience pain and/or discomfort during dental treatment. Still, pain research in dentistry has mainly been performed on adults using quantitative methods while research on the child's perspective is scarce. This study aims to explore and describe children's experiences and/or thoughts regarding pain in conjunction with tooth extraction.

    Material and methods: Interviews were carried out with twelve Swedish 10-16-year-olds who had recently undergone tooth extractions due to orthodontic reasons. Interviews were transcribed verbatim and analysed according to grounded theory.

    Results: A core category was identified and named 'handling the unavoidable unknown'. The informants recalled experiences of pain and discomfort during extractions. However, instead of focussing on pain, they described an urge for more information about the procedure and what to expect in terms of pain and/or discomfort, during and/or after treatment. They stated that the levels of pain/discomfort were manageable, while the lack of information negatively affected their coping abilities, causing feelings of unease.

    Conclusions: To improve patients' ability to deal with pain in conjunction with dental extraction, the dental team should ensure better and individually tailored information about the treatment. Thus, the use of psychological techniques is a cornerstone in pain management and must be reflected in clinical guidelines.

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  • 4.
    Klingberg, Gunilla
    et al.
    Malmö University, Faculty of Odontology (OD).
    Benchimol, Daniel
    Karolinska Institutet, Sweden.
    Berlin, Henrik
    Malmö University, Faculty of Odontology (OD).
    Bring, Johan
    Statisticon AB, Uppsala.
    Gornitzki, Carl
    Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm.
    Odeberg, Jenny
    Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm.
    Tranæus, Sofia
    Malmö University, Faculty of Odontology (OD). Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm.
    Twetman, Svante
    Department of Odontology, University of Copenhagen, Copenhagen, Denmark.
    Wernersson, Emma
    Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm.
    Östlund, Pernilla
    Malmö University, Faculty of Odontology (OD). Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm.
    Domeij, Helena
    Malmö University, Faculty of Odontology (OD). Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm.
    How old are you?: a systematic review investigating the relationship between age and mandibular third molar maturity2023In: PLOS ONE, E-ISSN 1932-6203, Vol. 18, no 5, p. 1-14, article id e0285252Article, review/survey (Refereed)
    Abstract [en]

    Introduction and objective: Radiographic evaluation of the maturity of mandibular third molars is a common method used for age estimation of adolescents and young adults. The aim of this systematic review was to examine the scientific base for the relationship between a fully matured mandibular third molar based on Demirjian's method and chronological age, in order to assess whether an individual is above or below the age of 18 years.

    Methods: The literature search was conducted in six databases until February 2022 for studies reporting data evaluating the tooth maturity using Demirjian´s method (specifically stage H) within populations ranging from 8 to 30 years (chronological age). Two reviewers screened the titles and abstracts identified through the search strategy independently. All studies of potential relevance according to the inclusion criteria were obtained in full text, after which they were assessed for inclusion by two independent reviewers. Any disagreement was resolved by a discussion. Two reviewers independently evaluated the risk of bias using the assessment tool QUADAS-2 and extracted the data from the studies with low or moderate risk of bias. Logistic regression was used to estimate the relationship between chronological age and proportion of subjects with a fully matured mandibular third molar (Demirjian´s tooth stage H).

    Results: A total of 15 studies with low or moderate risk of bias were included in the review. The studies were conducted in 13 countries and the chronological age of the investigated participants ranged from 3 to 27 years and the number of participants ranged between 208 and 5,769. Ten of the studies presented the results as mean age per Demirjian´s tooth stage H, but only five studies showed the distribution of developmental stages according to validated age. The proportion of subjects with a mandibular tooth in Demirjian´s tooth stage H at 18 years ranged from 0% to 22% among males and 0 to 16% in females. Since the studies were too heterogenous to perform a meta-analysis or a meaningful narrative review, we decided to refrain from a GRADE assessment.

    Conclusion: The identified literature does not provide scientific evidence for the relationship between Demirjian´s stage H of a mandibular third molar and chronologic age in order to assess if an individual is under or above the age of 18 years.

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  • 5.
    Castor, C.
    et al.
    Department of Health Sciences, Faculty of Medicine Lund University Lund Sweden.
    Björk, M.
    The CHILD Research Group, Department of Nursing, School of Health and Welfare Jönköping University Jönköping Sweden.
    Bai, J.
    Nell Hodgson Woodruff School of Nursing Emory University Atlanta Georgia USA.
    Berlin, Henrik
    Malmö University, Faculty of Odontology (OD).
    Kristjansdottir, G.
    Faculty of Nursing, School of Health Science University of Iceland Reykjavik Iceland.
    Kristjansdottir, O.
    Faculty of Nursing, School of Health Science University of Iceland Reykjavik Iceland.
    Hansson, H.
    Department of Paediatrics and Adolescent Medicine Copenhagen University Hospital Rigshospitalet Copenhagen Denmark;Department of Clinical Medicine University of Copenhagen Copenhagen Denmark.
    Höök, A.
    Division of Anaesthetics and Sensory Organs Speciality Surgery Linköping University Hospital Linköping Sweden.
    Stenström, P.
    Department of Pediatric Surgery Skåne University Hospital, Lund University Lund Sweden;Department of Paediatrics, Faculty of Medicine Lund University Lund Sweden.
    Nilsson, S.
    Department of Health Sciences, Faculty of Medicine Lund University Lund Sweden;Institute of Health and Care Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden.
    Psychometric evaluation of the electronic faces thermometer scale for pain assessment in children 8–17 years old: A study protocol2023In: Paediatric and Neonatal Pain, ISSN 2637-3807, Vol. 5, no 4, p. 99-109Article in journal (Refereed)
    Abstract [en]

    It is often a challenge for a child to communicate their pain, and their possibilities todo so should be strengthened in healthcare settings. Digital self-assessment providesa potential solution for person-centered care in pain management and promotes childparticipation when a child is ill. A child's perception of pain assessment differs when itis assessed using digital or analog formats. As we move into the digital era, there is anurgent need to validate digital pain assessment tools, including the newly developedelectronic Faces Thermometer Scale (eFTS). This study protocol describes three studies with the overall aim to evaluate psychometric properties of the eFTS for assessingpain in children 8–17 years of age. A multi-site project design combining quantitativeand qualitative methods will be used for three observational studies. Study 1: 100Swedish-speaking children will report the level of anticipated pain from vignettes describing painful situations in four levels of pain and a think-aloud method will be usedfor data collection. Data will be analyzed with phenomenography as well as descriptive and comparative statistics. Study 2: 600 children aged 8–17 years at pediatric anddental settings in Sweden, Denmark, Iceland, and USA will be included. Children willassess their pain intensity due to medical or dental procedures, surgery, or acute painusing three different pain Scales for each time point; the eFTS, the Faces Pain ScaleRevised, and the Coloured Analogue Scale. Descriptive and comparative statistics willbe used, with subanalysis taking cultural context into consideration. Study 3: A subgroup of 20 children out of these 600 children will be purposely included in an interview to describe experiences of grading their own pain using the eFTS. Qualitativedata will be analyzed with content analysis. Our pilot studies showed high level ofadherence to the study procedure and rendered only a small revision of backgroundquestionnaires. Preliminary analysis indicated that the instruments are adequate to beused by children and that the analysis plan is feasible. A digital pain assessment toolcontributes to an increase in pain assessment in pediatric care. The Medical ResearchCouncil framework for complex interventions in healthcare supports a thorough development of a new scale. By evaluating psychometric properties in several settingsby both qualitative and quantitative methods, the eFTS will become a well-validatedtool to strengthen the child's voice within healthcare.

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  • 6.
    Naimi-Akbar, Aron
    et al.
    Malmö University, Faculty of Odontology (OD).
    Berlin, Henrik
    Malmö University, Faculty of Odontology (OD).
    Klingberg, Gunilla
    Malmö University, Faculty of Odontology (OD).
    Roxner, Rikard
    Malmö University, Faculty of Odontology (OD).
    Vetenskapligt stöd saknas för påstående om anestesimedel2023In: Tandläkartidningen, ISSN 0039-6982, Vol. 115, no 9, p. 86-87Article in journal (Other (popular science, discussion, etc.))
  • 7.
    Berlin, Henrik
    Malmö University, Faculty of Odontology (OD).
    Procedural and postoperative pain in paediatric dentistry2020Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Tooth extraction is one of the most commonly performed dental treatments and there is always a risk of pain during and after this procedure. Pain is a major contributor to the development of dental fear and anxiety(DFA) and dental behaviour management problems (DBMP) in children and adolescents. These, in turn, are two of the most common reasons for referrals to specialist in paediatric dentistry. DFA and DBMP lead to reduced oral health and possibly suffering for the individual, as well as huge costs for society as a whole. It is therefore of uttermost importance that all dental treatments be performed with the aim of avoiding or minimising pain. The aims of this thesis were to (i) investigate how and to what extent Swedish dentists (both general dental practitioners and specialists inpaediatric dentistry) use different pain management strategies when treating children and adolescents, (ii) explain the natural course of pain after uncomplicated bilateral extractions of maxillary premolars in children between the ages of 10 and 15, (iii) systematically evaluate the effect of postoperatively administered over-the-counter oral analgesics as a means to minimise postoperative pain after oral surgery in children between the ages of 0 and 18, and finally (iv) gain greater insight into how children between the ages of 10 and 16 perceive the whole process of tooth extraction (during the procedure and after extraction) as part of orthodontic treatment. In the first study, a postal survey was sent to all active general dental practitioners (GDPs) in Skåne County, and to all specialists in paediatric dentistry (SPDs) in Sweden. The main findings were that pain management strategies differ between the two groups; in addition, GDPs used different strategies depending on whether primary or permanent teeth were being treated. In general, the survey found an underuse of local anaesthesia by general dentists. This calls for guidelines on pain management strategies in paediatric dental care. In the second study, pain intensity was measured at 14 different time points after tooth extraction performed prior to orthodontic treatment, in a sample of 31 children 10 to15 years of age. Pain intensity after extraction of an upper tooth was generally mild to moderate. The natural course of pain intensity followed the same pattern regardless of how the data were analysed. Pain peaked at 2 hours after treatment, then decreasing rapidly until the next measurement that took place 4 hours after treatment. There was no difference between the first and second extraction, indicating that this model is an excellent one for further research on pain management strategies, with no carryover effect. The third study was a systematic review(SR) and health technology assessment (HTA). A systematic review regarding preoperatively administered oral analgesics has been previously published, but it does not present any scientific evidence showing their administration as providing additional pain relief in children after dental treatment. An SR/HTA looked at postoperatively administered oral analgesics with the goal of minimising postoperative pain after oral surgical therapies in children. This SR/HTA yielded an empty review. As of today, there is no scientific evidence for the effectiveness of the administration of oral analgesics postoperatively in order to minimise postoperative pain after oral surgical therapies in children aged 0–18 years. Neither is there any evidence to reject this strategy. This highlights the need for well-designed primary studies on this topic. In the fourth and final study of this thesis, children’s perception of tooth extraction and the postoperative period was investigated in order to better understand the child’s perspective regarding this treatment. A qualitative research approach, using grounded theory, was used. Although the subjects were a bit anxious before the procedure, they all managed to handle the treatment using different types of coping strategies. One central theme that emerged from analysing the interviews was the importance of getting proper information from dental staff, at the right time. Children who received adequate information were able to withstand some pain and discomfort. Having some form of control over the situation also emerged as a coping strategy.

    Conclusions

    Among Swedish dentists (both GDPs and SPDs), there seems to be uncertainty regarding pain management strategies in children and adolescents in terms of the use of local anaesthetics and oral analgesics. There are differences in pain management strategies between GDPs and SPDs. The majority of the participants perceived pain intensity after tooth extraction due to orthodontic indication to be mild to moderate. These types of extractions can serve as a good model for future pain research. The amount of pain research on paediatric populations in dentistry is scarce. We need more well-designed primary studies before guidelines on pain management strategies for paediatric dental care can be formulated. When given proper and honest information at the right time, children are able to cope with dental treatments, even if they are a bit anxious beforehand and even if they perceive pain or discomfort during and after treatment.

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  • 8.
    Berlin, Henrik
    et al.
    Malmö University, Faculty of Odontology (OD).
    Vall, Martina
    Malmö University, Malmö University Library.
    Bergenäs, Elisabeth
    Malmö University, Malmö University Library.
    Ridell, Karin
    Malmö University, Faculty of Odontology (OD).
    Brogårdh-Roth, Susanne
    Malmö University, Faculty of Odontology (OD).
    Lager, Elisabeth
    Malmö University, Faculty of Odontology (OD).
    List, Thomas
    Malmö University, Faculty of Odontology (OD).
    Davidson, Thomas
    Malmö University, Faculty of Odontology (OD).
    Klingberg, Gunilla
    Malmö University, Faculty of Odontology (OD).
    Effects and cost-effectiveness of postoperative oral analgesics for additional postoperative pain relief in children and adolescents undergoing dental treatment: Health technology assessment including a systematic review2019In: PLOS ONE, E-ISSN 1932-6203, Vol. 14, no 12, article id e0227027Article, review/survey (Refereed)
    Abstract [en]

    Background There is an uncertainty regarding how to optimally prevent and/or reduce pain after dental treatment on children and adolescents. Aim To conduct a systematic review (SR) and health technology assessment (HTA) of oral analgesics administered after dental treatment to prevent postoperative pain in children and adolescents aged 3-19 years. Design A PICO-protocol was constructed and registered in PROSPERO (CRD42017075589). Searches were conducted in PubMed, Cochrane, Scopus, Cinahl, and EMBASE, November 2018. The researchers (reading in pairs) assessed identified studies independently, according to the defined inclusion and exclusion criteria, following the PRISMA-statement. Results 3,963 scientific papers were identified, whereof 216 read in full text. None met the inclusion criteria, leading to an empty SR. Ethical issues were identified related to the recognized knowledge gap in terms of challenges to conduct studies that are well-designed from methodological as well as ethical perspectives. Conclusions There is no scientific support for the use or rejection of oral analgesics administered after dental treatment in order to prevent or reduce postoperative pain in children and adolescents. Thus, no guidelines can be formulated on this issue based solely on scientific evidence. Well-designed studies on how to prevent pain from developing after dental treatment in children and adolescents is urgently needed.

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  • 9.
    Berlin, Henrik
    et al.
    Malmö University, Faculty of Odontology (OD).
    List, Thomas
    Malmö University, Faculty of Odontology (OD).
    Ridell, Karin
    Malmö University, Faculty of Odontology (OD).
    Davidson, Thomas
    Toft, Danijela
    Klingberg, Gunilla
    Malmö University, Faculty of Odontology (OD).
    Postoperative pain profile in 10-15-year-olds after bilateral extraction of maxillary premolars2019In: European Archives of Paediatric Dentistry, ISSN 1818-6300, E-ISSN 1996-9805, Vol. 20, no 6, p. 545-555Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To study pain perception in 10-15-year-olds, during and after uncomplicated extractions of bilateral maxillary premolars. The study investigated pain's natural course and made comparisons between the first and second extractions. METHODS: 31 Swedish children in need of orthodontic treatment were identified and consecutively enrolled. Tooth extractions followed a standardised protocol and the two teeth were extracted with at least 10 days between. The participants rated pain intensity using visual analogue scale (VAS) at 14 different time points from treatment and 7 days forward. RESULTS: The pain intensity profile followed the same pattern for all patients. Pain intensity peaked 2 h after extractions (mean VASPI 27.3, SD 20.8; median 23.0) when moderate pain intensity (VASPI >/= 40) was registered for 16 (28%) of 57 cases. After that, there was a rapid decrease in pain intensity notable already at 4 h after extractions. There were no statistically significant differences in any VASPI measurements between the first and second extractions, sexes, or different age groups. CONCLUSIONS: The majority of the participants who undergo uncomplicated bilateral extraction of maxillary premolars experience mild to moderate levels of postoperative pain during a short period of time, with no differences between the first and second extractions. Bilateral tooth extractions is a suitable model for further studies on pain management.

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  • 10.
    Berlin, Henrik
    et al.
    Malmö University, Faculty of Odontology (OD).
    List, Thomas
    Malmö University, Faculty of Odontology (OD).
    Ridell, Karin
    Malmö University, Faculty of Odontology (OD).
    Klingberg, Gunilla
    Malmö University, Faculty of Odontology (OD).
    Dentists' attitudes towards acute pharmacological pain management in children and adolescents2018In: International Journal of Paediatric Dentistry, ISSN 0960-7439, E-ISSN 1365-263X, Vol. 28, no 2, p. 152-160Article in journal (Refereed)
    Abstract [en]

    AIM: This study aimed to investigate Swedish dentists' attitudes regarding pain management strategies for treating children and adolescents. It assessed recommendations for pre- and postoperative analgesics, and use of local anaesthesia, and whether application of these strategies differs between general dental practitioners (GDPs) and specialists in paediatric dentistry (SPDs). DESIGN: We invited all GDPs (n = 807) in southern Sweden (Region Skåne), and all registered SPDs (n = 122) working in Sweden (929 actively practising dentists under age 65 years) to participate in a postal survey on pain management in paediatric dental care. RESULTS: The SPDs reported using all types of pain-reducing strategies more frequently than GDPs except local anaesthesia when extracting a permanent premolar, which SPDs and GDPs used equally often. Preoperative analgesic use was greater among SPDs than GDPs. GDPs used local anaesthesia less frequently for filling therapy in primary teeth than in permanent teeth. CONCLUSIONS: SPDs recommend preoperative analgesics more often than GDPs do. GDPs seem to underuse local anaesthetics when treating children and adolescents. SPDs also use pain management strategies more frequently than GDPs. Among GDPs, pain management is less frequent when treating primary teeth than permanent teeth.

  • 11.
    Klingberg, Gunilla
    et al.
    Malmö högskola, Faculty of Odontology (OD).
    Ridell, Karin
    Malmö högskola, Faculty of Odontology (OD).
    Brogårdh-Roth, Susanne
    Malmö högskola, Faculty of Odontology (OD).
    Vall, Martina
    Malmö högskola, Library and IT Services (BIT).
    Berlin, Henrik
    Malmö högskola, Faculty of Odontology (OD).
    Local analgesia in paediatric dentistry: a systematic review of techniques and pharmacologic agents2017In: European Archives of Paediatric Dentistry, ISSN 1818-6300, E-ISSN 1996-9805, Vol. 18, no 5Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate the evidence supporting effects and adverse effects of local analgesia using different pharmacological agents and injection techniques during dental treatment in children and adolescents aged 3-19 years. METHODS: A systematic literature search of databases including PubMed, Cochrane, and Scopus was conducted in November 2016. The PRISMA-statement was followed. Two review authors independently assessed the selected randomised control trials for risk of bias and quality. RESULTS: 725 scientific papers were identified. 89 papers were identified to be read in full text of which 80 were excluded. Finally, 9 papers were evaluated for quality and risk of bias. Many of the included papers had methodological shortcomings affecting the possibility to draw conclusions. Information about ethical clearance and consent were missing in some of the included papers. No alarming adverse effects were identified. One study was assessed as having low risk of bias. This reported inferior alveolar nerve block to be more effective than buccal infiltration for dental treatment of mandibular molars, while no differences were found regarding pharmacological agents. CONCLUSIONS: At present, there is insufficient evidence in support of any pharmacologic agent or injection technique as being superior compared to others. There is a need for more rigorous studies which also handle the ethical issues of including children in potentially painful studies.

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