Effective local anesthesia in pediatric dentistry is essential for pain control, successful dental treatment, and the development of positive dental experiences.
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Advances in dental technology have introduced several local anesthesia delivery systems, including conventional aspirating syringes, computer-controlled local anesthetic delivery (CCLAD), and alternative injection techniques. These approaches aim to improve injection comfort, control anesthetic deposition, and reduce procedural anxiety.
This guide reviews the principal anesthesia systems used in pediatric dentistry, their clinical applications, advantages, and limitations, emphasizing evidence-based selection.
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The systems used in pediatric dentistry differ in how the anesthetic solution is delivered, the degree of injection control, and the clinical situations in which they are most useful.
1. Conventional Dental Syringe System
The conventional aspirating dental syringe remains the most widely used system for administering local anesthesia in children.
It consists of a reusable or disposable syringe, an anesthetic cartridge, and a disposable needle. It allows infiltration anesthesia and regional nerve blocks.
▪️ Advantages: Low cost, widespread availability, familiarity, and versatility.
▪️ Limitations: Injection pressure and anesthetic flow depend largely on operator control. Rapid deposition may increase discomfort.
▪️ Clinical applications: Maxillary infiltration, inferior alveolar nerve block, and other conventional regional techniques.
2. Computer-Controlled Local Anesthetic Delivery (CCLAD)
Computer-controlled local anesthetic delivery (CCLAD) systems use electronic mechanisms to regulate anesthetic flow and injection rate, reducing dependence on manual pressure.
Examples include:
▪️ The Wand/STA: Uses a pen-like handpiece and controlled anesthetic delivery. It is particularly useful for periodontal ligament injections and other precision techniques.
▪️ Dentapen: A compact electronic system designed to provide controlled anesthetic delivery.
▪️ QuickSleeper: Combines electronic injection control with rotary needle penetration to facilitate intraosseous anesthesia.
Advantages:
▪️ More consistent injection flow.
▪️ Improved control of anesthetic deposition.
▪️ Potential reduction in injection-related pain and anxiety.
▪️ Greater patient acceptance in selected pediatric procedures.
Limitations: Higher equipment costs, additional training, and variable evidence depending on the injection technique and outcome measured.
A 2025 systematic review and meta-analysis involving 20 randomized clinical trials found significantly lower pain scores with CCLAD according to the Wong-Baker scale, although results varied across assessment methods and the certainty of evidence ranged from very low to moderate (Shirani et al., 2025).
3. Needle-Free Jet Injection Systems
Needle-free injection systems deliver anesthetic through a high-pressure stream that penetrates the mucosa without a conventional needle.
▪️ Advantages: Avoidance of needle penetration and potential reduction of needle-related fear.
▪️ Limitations: Variable penetration depth, limited control over the distribution of anesthetic, and possible discomfort from the pressure of delivery.
▪️ Clinical applications: Selected superficial anesthesia procedures, depending on the device and its approved indications.
These systems should not be considered universal replacements for conventional infiltration or nerve block techniques. Evidence supporting their routine use in pediatric dentistry remains limited.
4. Conventional Syringe with Topical Anesthesia
Topical anesthesia is an important complementary approach before needle insertion. It produces superficial mucosal anesthesia and helps reduce discomfort during penetration.
Common agents include:
▪️ Benzocaine: Commonly available in 20% preparations.
▪️ Lidocaine: Available in different topical formulations and concentrations.
The application should be limited to the recommended amount and duration. Systemic absorption must be considered when calculating total anesthetic exposure.
Important safety consideration: Benzocaine is contraindicated in children younger than two years and in patients with a history of methemoglobinemia.
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In addition to the delivery systems, several injection techniques can improve anesthetic effectiveness or provide alternatives when conventional anesthesia is insufficient.
| Technique | Main Application | Clinical Considerations |
|---|---|---|
| Supraperiosteal infiltration | Maxillary teeth and selected mandibular primary teeth | Common first-line technique, depending on anatomy |
| Inferior alveolar nerve block (IANB) | Mandibular teeth on the anesthetized side | May produce prolonged lip and tongue numbness |
| Intraligamentary (PDL) | Localized anesthesia of individual teeth | Useful when soft-tissue anesthesia should be minimized |
| Intraosseous | Rapid anesthesia of selected teeth | Useful when conventional techniques provide inadequate pulpal anesthesia |
| Intrapulpal | Pulpal procedures when other techniques fail | Requires direct pulp exposure; pressure during injection contributes to effectiveness |
| Intraseptal | Interdental soft tissues and localized anesthesia | Can complement other injection techniques |
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The following table summarizes their principal characteristics and clinical applications.
| System | Main advantage | Main limitation |
|---|---|---|
| Conventional syringe | Versatility and accessibility | Operator-dependent injection pressure |
| CCLAD | Controlled anesthetic flow | Cost and equipment requirements |
| Needle-free jet | Avoids conventional needle penetration | Limited clinical indications |
| Topical anesthesia | Reduces mucosal penetration discomfort | Does not provide reliable pulpal anesthesia |
Regardless of the delivery system, patient safety and accurate anesthetic dosage remain the primary considerations.
The following factors should be evaluated:
▪️ Body weight: Calculate the maximum dose in mg/kg rather than relying on age alone.
▪️ Medical history: Consider allergies, hepatic conditions, cardiovascular disorders, and susceptibility to methemoglobinemia.
▪️ Anesthetic selection: Consider the procedure, expected duration, and use of sedation or other medications.
▪️ Aspiration: Perform aspiration when indicated and administer the solution slowly.
▪️ Soft-tissue injury: Explain the duration of numbness and prevent lip, cheek, or tongue biting.
▪️ Documentation: Record the anesthetic agent, concentration, total volume, calculated dose, injection technique, and location.
According to AAPD recommendations, the long-established conservative maximum dose for lidocaine in pediatric dental patients is 4.4 mg/kg, whereas the manufacturer's recommended maximum is 7 mg/kg. The lowest effective dose should be used.
Articaine is not recommended by manufacturers for children younger than four years. Additional precautions apply to prilocaine, benzocaine, and other agents associated with methemoglobinemia.
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The development of modern local anesthesia delivery systems has expanded the options available for pain management in pediatric dentistry. Conventional syringes remain essential because of their versatility, accessibility, and ability to perform different infiltration and nerve block techniques.
However, CCLAD systems represent an important technological advancement. Their ability to regulate injection speed and pressure may improve patient comfort, particularly in children with dental anxiety.
Evidence is encouraging but should be interpreted cautiously. Shirani et al. (2025) reported a significant reduction in pain with CCLAD, while previous systematic reviews have identified substantial heterogeneity and inconsistent differences between computerized and conventional techniques.
A randomized controlled trial by Prol Castelo et al. (2023) also demonstrated favorable results with computer-controlled intraligamentary and intraosseous anesthesia compared with conventional inferior alveolar nerve block in children.
Therefore, the effectiveness of local anesthesia depends not only on the delivery system but also on the injection technique, operator expertise, patient characteristics, and appropriate anesthetic selection.
✍️ Conclusion
Local anesthesia systems in pediatric dentistry provide different approaches to achieving effective pain control and improving the dental experience of children.
Although conventional syringes remain the foundation of pediatric dental anesthesia, CCLAD systems offer additional advantages through controlled anesthetic delivery. Needle-free devices and alternative injection techniques may also have selected clinical applications.
The most appropriate approach should be determined by clinical indications, patient cooperation, anatomical considerations, and safety requirements rather than technological preference alone.
🎯 Clinical Recommendations
▪️ Prioritize effective anesthesia: Select the technique according to the tooth, procedure, and anatomical characteristics rather than relying on a single universal approach.
▪️ Consider CCLAD for anxious children: Particularly when controlled injection flow may facilitate treatment acceptance.
▪️ Use alternative techniques selectively: Intraligamentary and intraosseous anesthesia can be considered when conventional approaches are insufficient or when limiting soft-tissue numbness is desirable.
▪️ Individualize anesthetic dosage: Calculate the maximum dose according to body weight and account for all sources of anesthetic exposure.
▪️ Evaluate treatment outcomes: Consider patient-reported pain, behavioral response, anesthetic effectiveness, and postoperative complications when selecting a delivery system.
📚 References
✔ American Academy of Pediatric Dentistry. (2025). Use of local anesthesia for pediatric dental patients. In The Reference Manual of Pediatric Dentistry (pp. 407–414). American Academy of Pediatric Dentistry. https://www.aapd.org/research/oral-health-policies--recommendations/use-of-local-anesthesia-for-pediatric-dental-patients/
✔ Shirani, M., Azizmohammad Looha, M., & Emami, M. (2025). Comparison of injection pain levels using conventional and computer-controlled local anesthetic delivery systems in pediatric dentistry: A systematic review and meta-analysis. Journal of Dentistry, 157, 105770. https://doi.org/10.1016/j.jdent.2025.105770
✔ Prol Castelo, A., García Mato, E., Varela Aneiros, I., Sande López, L., Outumuro Rial, M., Abeleira Pazos, M. T., Rivas Mundiña, B., & Limeres Posse, J. (2023). Evaluation of intraligamentous and intraosseous computer-controlled anesthetic delivery systems in pediatric dentistry: A randomized controlled trial. Children, 10(1), 79. https://doi.org/10.3390/children10010079
✔ Pozos-Guillén, A., Loredo-Cruz, E., Esparza-Villalpando, V., Martínez-Rider, R., Noyola-Frías, M., & Garrocho-Rangel, A. (2020). Pain and anxiety levels using conventional versus computer-controlled local anesthetic systems in pediatric patients: A meta-analysis. The Journal of Clinical Pediatric Dentistry, 44(6), 371–399. https://doi.org/10.17796/1053-4625-44.6.1
✔ Altuhafy, M., Sodhi, G. S., & Khan, J. (2024). Efficacy of computer-controlled local anesthesia delivery system on pain in dental anesthesia: A systematic review of randomized clinical trials. Journal of Dental Anesthesia and Pain Medicine, 24(4), 245–264. https://doi.org/10.17245/jdapm.2024.24.4.245
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