Many authors have found that, in many cases, dental care anxiety is not activated by direct triggers, but rather by visual or noisy stimuli typical of dental offices.

On the other hand, it is undeniable how, in many cases, pain actually triggers problematic behavior. Moreover, we are not talking about isolated problems but about events that can occur systematically. As noted by Nakai, more than one in 10 children report a personal history of intraoperative dental pain. Further, Kaufman observed that, during a regular workweek evaluation, at least one dentist out of 10 encounters at least one anesthesiological failure to such a degree as to lead to discontinuation of treatment. The failure rates reported in literature vary depending on the anesthetic technique and also on the target area and patient clinical condition (for example in the presence of pulpitis). Molars (deciduous and permanent) and upper incisors are, in this sense, critical areas. Intraligament, buccal, posterior superior alveolar, greater palatine and incisor canal nerve block anesthetic procedures are particularly indicated for computer-guided anesthesia management.

It therefore seems an essential prerequisite to ensure that the pediatric patient has an adequate anesthesiological regimen. According to this logic, more complex measures, such as general anesthesia, should be regarded as a second choice, and even an extrema ratio indicated for the management of particularly complex cases.

In this regard, in an article published in the International Journal of Clinical Pediatric Dentistry, an Israeli working group recently shared a small case series. The authors reported a total of six pediatric cases with subjects that completed their respective dental care plans under general anesthesia, which were examined for a second opinion. All patients had exhibited destructive behavior.

The re-evaluation revealed the lack of responsiveness of all patients to routine local anesthesia techniques. In all cases, it was possible to avoid general anesthesia by adopting different approaches to increase the effectiveness of local anesthesia. In three cases additional anesthesia was used, in two others, an anesthetic molecular change was implemented and, in the remaining case, the same molecule was used at a maximum dosage. It should be note that, in all cases, simply formulating an adequate local anesthesia regimen was sufficient in obtaining full collaboration from the patients.

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