Effect of photobiomodulation therapy on pain perception during anesthetic puncture of dental local anesthesia: A systematic review

Mesquita, Caio Melo; Oliveira, Millena Barroso; Costa, Marcelo Dias Moreira de Assis; Vieira, Walbert Andrade; Lima, Rafael Rodrigues; Rode, Sigmar de Mello; Paranhos, Luiz Renato

doi:10.1016/j.clinsp.2023.100322

Caio Melo Mesquita

Conceptualization

Investigation

Methodology

Data curation

Validation

Writing - original draft

Writing - review & editing

School of Dentistry, Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brazil

https://orcid.org/0000-0002-6892-3659

Millena Barroso Oliveira

Conceptualization

Investigation

Methodology

Data curation

Validation

Writing - original draft

Writing - review & editing

Postgraduate Program in Dentistry, School of Dentistry, Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brazil

https://orcid.org/0000-0001-5878-781X

Marcelo Dias Moreira de Assis Costa

Conceptualization

Investigation

Methodology

Data curation

Validation

Writing - original draft

Writing - review & editing

Postgraduate Program in Dentistry, School of Dentistry, Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brazil

https://orcid.org/0000-0001-9148-3674

Walbert Andrade Vieira

Methodology

Data curation

Validation

Writing - original draft

Writing - review & editing

Supervision

Department of Restorative Dentistry, Endodontics Division, School of Dentistry, Universidade Estadual de Campinas (UNICAMP), Piracicaba, SP, Brazil

https://orcid.org/0000-0001-8872-2865

Rafael Rodrigues Lima

Methodology

Data curation

Validation

Writing - review & editing

Supervision

Laboratory of Functional and Structural Biology, Institute of Biological Sciences, Universidade Federal do Pará (UFPA), Belém, PA, Brazil

https://orcid.org/0000-0003-1486-4013

Sigmar de Mello Rode

Methodology

Data curation

Validation

Writing - review & editing

Supervision

Department of Dental Materials and Prosthetics, Institute of Science and Technology, Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), São Paulo, SP, Brazil

https://orcid.org/0000-0002-4261-4217

Luiz Renato Paranhos ^** Corresponding author. E-mail address:paranhos.lrp@gmail.com (L.R. Paranhos)

Conceptualization

Investigation

Methodology

Data curation

Validation

Writing - original draft

Writing - review & editing

Supervision

Division of Social and Preventive Dentistry, School of Dentistry, Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brazil

https://orcid.org/0000-0002-7599-0120

* Corresponding author. E-mail address:paranhos.lrp@gmail.com (L.R. Paranhos)

Conflicts of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.

Databases	Search Strategy (November 2021) and Update (June 2022)
Main Databases
Embase https://www.embase.com	('lasers' OR 'laser therapy' OR 'low level laser therapy' OR 'low level light therapy' OR 'photobiomodulation' OR 'photobiomodulation therapy' OR 'laser biostimulation' OR 'laser phototherapy') AND ('pain' OR 'pain management' OR 'pain perception' OR 'pain measurement') AND ('anesthesia' OR 'dental anesthesia' OR 'surgery, oral' OR 'oral surgical procedures' OR 'oral surgery' OR 'oral procedure' OR 'dental surgery' OR 'dental procedures')
LILACS and BBO http://pesquisa.bvsalud.org/	/pt (("Lasers" OR "Terapia a Laser" OR "Terapia com Luz de Baixa Intensidade" OR "Bioestimulação a Laser" OR "Irradiação a Laser de Baixa Intensidade" OR "Irradiação a Laser de Baixa Potência" OR "Terapia a Laser de Baixa Intensidade" OR "Terapia a Laser de Baixa Potência") AND ("Dor" OR "Manejo da Dor" OR "Percepção da Dor" OR "Mensuração da Dor") AND (“anestesia” OR “anestesia dentária” OR "Cirurgia Bucal" OR "Procedimentos Cirúrgicos Bucais" OR "Cirurgia Oral" OR "Procedimentos Orais")) AND (db:("LILACS" OR "BBO"))
LILACS and BBO http://pesquisa.bvsalud.org/	/en (("Lasers" OR "Laser Therapy" OR "Low Level Laser Therapy" OR "Low Level Light Therapy" OR "Photobiomodulation" OR "Photobiomodulation Therapy" OR "Laser Biostimulation" OR "Laser Phototherapy") AND ("Pain" OR "Pain Management" OR "Pain Perception" OR "Pain Measurement") AND ("Anesthesia" OR "Anesthesia, Dental" OR "Surgery, Oral" OR "Oral Surgical Procedures" OR "Oral Surgery" OR "Oral Procedure")) AND (db:("LILACS" OR "BBO"))
LIVIVO https://www.livivo.de/	#1 ("Lasers" OR "Laser Therapy" OR "Low Level Laser Therapy" OR "Low Level Light Therapy" OR "Photobiomodulation" OR "Photobiomodulation Therapy" OR "Laser Biostimulation" OR "Laser Phototherapy")
	#2 ("Pain" OR "Pain Management" OR "Pain Perception" OR "Pain Measurement")
	#3 ("Anesthesia" OR "Anesthesia, Dental" OR "Surgery, Oral" OR "Oral Surgical Procedures" OR "Oral Surgery" OR "Oral Procedure" OR "Dental Surgery" OR "Dental Procedures")
	#1 AND #2 AND #3
MEDLINE (via PubMed) http://www.ncbi.nlm.nih.gov/pubmed	#1 “Lasers”(Mesh) OR “Laser Therapy”(Mesh) OR “Low Level Laser Therapy”(tw) OR “Low Level Light Therapy”(tw) OR "Photobiomodulation"(tw) OR "Photobiomodulation Therapy"(tw) OR "Laser Biostimulation"(tw) OR "Laser Phototherapy"(tw)
	#2 "Pain"(Mesh) OR "Pain Management"(Mesh) OR "Pain Perception"(Mesh) OR "Pain Measurement"(Mesh)
	#3 "Anesthesia"(Mesh) OR "Anesthesia, Dental"(Mesh) OR “Oral Anesthesia”(tw) OR “Teeth Anesthesia”(tw) OR "Surgery, Oral"(Mesh) OR "Oral Surgical Procedures"(Mesh) OR "Oral Surgery"(tw) OR "Oral Procedure"(tw) OR "Dental Surgery"(tw) OR "Dental Procedures"(tw)
	#1 AND #2 AND #3
SciELO https://scielo.org/	(("Lasers" OR "Laser Therapy" OR "Low Level Laser Therapy" OR "Low Level Light Therapy" OR "Photobiomodulation" OR "Photobiomodulation Therapy" OR "Laser Biostimulation" OR "Laser Phototherapy") AND ("Pain" OR "Pain Management" OR "Pain Perception" OR "Pain Measurement") AND ("Anesthesia" OR "Anesthesia, Dental" OR "Surgery, Oral" OR "Oral Surgical Procedures" OR "Oral Surgery" OR "Oral Procedure"))
Scopus http://www.scopus.com/	(TITLE-ABS-KEY (("Lasers" OR "Laser Therapy" OR "Low Level Laser Therapy" OR "Low Level Light Therapy" OR "Photobiomodulation" OR "Photobiomodulation Therapy" OR "Laser Biostimulation" OR "Laser Phototherapy")) AND TITLE-ABS-KEY (("Pain" OR "Pain Management" OR "Pain Perception" OR "Pain Measurement")) AND TITLE-ABS-KEY (("Anesthesia" OR "Anesthesia, Dental" OR "Surgery, Oral" OR "Oral Surgical Procedures" OR "Oral Surgery" OR "Oral Procedure" OR "Dental Surgery" OR "Dental Procedures")))
Web of Science http://apps.webofknowledge.com/	#1 TS=("Lasers" OR "Laser Therapy" OR "Low Level Laser Therapy" OR "Low Level Light Therapy" OR "Photobiomodulation" OR "Photobiomodulation Therapy" OR "Laser Biostimulation" OR "Laser Phototherapy")
	#2 TS=("Pain" OR "Pain Management" OR "Pain Perception" OR "Pain Measurement")
	#3 TS=("Anesthesia, Dental" OR "Oral Anesthesia" OR "Teeth Anesthesia" OR "Surgery, Oral" OR "Oral Surgical Procedures" OR "Oral Surgery" OR "Oral Procedure" OR "Dental Surgery" OR "Dental Procedures")
	#1 AND #2 AND #3
Gray Literature
EASY https://easy.dans.knaw.nl/	("Lasers" OR "Dental Anesthesia")
Google Scholar https://scholar.google.com.br/	("Lasers") AND ("Dental Anesthesia") filetype:pdf
OATD http://www.oatd.org/	(("Lasers") AND ("Anesthesia"))

Author, year (country)	Study design	Sample (♀, ♂)	Mean age ± SD	Laser specifications (brand of device)	Laser application protocol	Anesthetic technique protocol	Pain assessment method
Dantas et al., 2011 (Brazil) ^[24][24] Dantas E.M., de Carvalho C.M., Batista S.H.B., de Menezes M.R.A., Dantas W.R.M. Efeito antiálgico do laser AsGaAl na punção anestésica. [Analgesic Effect of GaAlAs Laser on Anesthetic Action]. Rev Cir Traumatol Buco-Maxilo-Fac. 2011;11(2):75-82. Portuguese.	Parallel	60 (nr) 20 - Control 1: light curing 20 - Control 2: no treatment 20 - Test: PBMT	nr	Gallium aluminum arsenide	Applied at the anesthetic puncture site for 33 s.	Injection of ¹/₄ of the local anesthetic cartridge (Novocol, SS White) in the palate region, approximately 3 mm above the cervical region of the teeth to be anesthetized.	10-score VNS applied after injection.
				Wavelength: 830 nm
				Power: 120 mW
				Focal spot: 2 mm²
				Energy density: 4 J/cm²
Sattayut, 2014 (Thailand) ^[25][25] Sattayut S. Low intensity laser for reducing pain from anesthetic palatal injection. Photomed Laser Surg. 2014;32(12):658-62.	Parallel	80 (40♀, 40♂) 20 - Control: topical anesthesia 20 - Test: Pressure 20 - Test: PBMT without radiation 20 - Test: PBMT	21 ± nr ^a a Age range. 18 to 25 years old	Wavelength: 790 nm	Applied at the anesthetic puncture site for 2 min in contact mode.	Injection of 0.5 mL of 2% lidocaine hydrochloride solution with 1:100,000 epinephrine into the anesthetized area using a pressure and volume control intraligamental syringe and a 27-gauge disposable needle (Citojet, Bayer, Germany).	100 mm VAS applied after injection.
				Continuous mode
				Power: 30 mW
				Focal spot: 0.13 cm²
				Energy density: 27.69 J/cm²
Ghaderi et al., 2016 (Iran) ^[26][26] Ghaderi F., Ghaderi R., Davarmanesh M., Bayani M., Moghadam S.A. Pain management during needle insertion with low level laser. Eur J Paediatr Dent. 2016;17(2):151-4.	Split-mouth	66 (30♀, 36♂) 66 - Control: topical anesthesia 66 - Test: topical anesthesia + PBMT	23.34 ± 2.16	Gallium Aluminum Arsenide (AZERO K2, Russia)	Mucosa was isolated and dried for 30 s with a cotton. Local anesthetic gel (benzocaine) was applied for 60 s. Photobiomodulation was applied at the anesthetic puncture site for 1 min.	Insertion of a 27-gauge short needle into the buccal mucosa of the maxillary canine region after laser irradiation for the laser group and after application of topical anesthetic for the placebo group.	100 mm VAS applied after needle insertion.
				Wavelength: 960 nm
				Continuous mode
				Power: 100 mW
				Focal spot: nr
				Energy density: 4 J/cm²
Tuk et al., 2017 (Netherlands) ^[27][27] Tuk J.G.C., van Wijk A.J., Mertens I.C., Keleş Z., Lindeboom J.A.H., Milstein D.M.J. Analgesic effects of preinjection low-level laser/light therapy (LLLT) before third molar surgery: a double-blind randomized controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;124(3):240-7.	Parallel	163 (82♀, 81♂) 80 - Control: no treatment 83 - Test: PBMT	L (32 ± 14); P (29 ± 12); ^a a Age range. 18 to 75 years old	LX2 Control Unit with laser probe (THOR Photomedicine Ltd., Chesham, UK)	Both maxilla and mandible had 2 target-sites irradiated for 30 s continuously, and each target-site was also irradiated twice in a row. Total irradiation time was 2 min (1 min for each target-site) with a 30 s interval between each irradiation.	Local anesthesia or mandibular block was performed with 4% articaine hydrochloride with 1:100,000 epinephrine (1.7-mL syringe Ultracain D-S forte, Sanofi-Aventis Netherlands BV, Gouda, Netherlands), using a 27-G needle (Terumo 27 13/8, Somerset, NJ).	11-point NRS applied before and immediately after injection.
				Wavelength: 810 nm
				Continuous mode
				Power: 198 mW
				Focal spot: 0.088 cm²
				Energy density: 67.5 J/cm²
Jagtap et al., 2019 (India) ^[28][28] Jagtap B., Bhate K., Magoo S., Santhoshkumar N.S., Gajendragadkar K.S., Joshi S. Painless injections-a possibility with low level laser therapy. J Dent Anesth Pain Med. 2019;19(3):159-65.	Split-mouth	25 (12♀, 13♂) 25 - Control: PBMT without radiation 25 - Test: PBMT	28.3 ± 5.5 ^a a Age range. 18 to 60 years old	Microcontroller Based Diode Laser (Silberbauer, India)	Applied at the anesthetic puncture site for 3 min.	Standard local anesthetic was injected to perform the blocking technique.	10-score VAS applied after injection.
				Wavelength: 660 nm
				Power: 60 mW
				Focal spot: nr
				Energy density: nr
Ghabraei et al., 2020 (Iran) ^[29][29] Ghabraei S., Bolhari B., Nashtaie H.M., Noruzian M., Niavarzi S., Chiniforush N. Effect of photobiomodulation on pain level during local anesthesia injection: a randomized clinical trial. J Cosmet Laser Ther. 2020;22(4-5):180-4.	Parallel	56 (29♀, 27♂) 22 - Control: PBMT without radiation 12 - Control: no treatment 22 - Test: PBMT	L (39.2 ± 12.2) P (37.6 ± 12) C (37.8 ± 11) ^a a Age range. 18 to 60 years old	Simpler Diode Laser (Doctorsmile, Italy)	Applied at the anesthetic puncture site (buccal mucosa) for 20 s continuously.	A tube of 2% lidocaine with 1:80,000 epinephrine (Daroo Pakhsh, Iran) was injected in the anterior buccal region of the maxilla completely at a rate of 1 mL/min with a 27-gauge short needle (Technofar, Italy).	170 mm VAS.
				Wavelength: 980 nm
				Power: 300 mW
				Focal spot: 0.384 cm²
				Energy density: 15.62 J/cm²
Amruthavarshini et al., 2021 (India) ^[30][30] AmruthaVarshini I., Vinay C., Uloopi K.S., RojaRamya K.S., Chandrasekhar R., Penmatsa C. Effectiveness of pre-cooling the injection site, laser biostimulation, and topical local anesthetic gel in reduction of local anesthesia injection pain in children. Int J Clin Pediatr Dent. 2021;14(1):81-3.	3-arm, crossover	30 (NR) 30 - Control: topical anesthesia 30 - Test 1: Ice application 30 - Test 2: PBMT	Nr ^a a Age range. 9 to 12 years old	DenLase Diode Laser (China Daheng Group, Inc., China)	Mucosa was properly isolated and dried. Photobiomodulation was applied at anesthetic puncture site for 1 min in pulsed mode and 2 mm away from the surface.	An injection of local anesthetic solution (Lignox 2% A, Kilitch Drugs India Ltd., Navi Mumbai) was performed at 1 mL/min.	WBFPRS and SEM scales applied during injection.
				Wavelength: 810 nm
				Pulsed mode
				Power: 300 mW
				Focal spot: nr
				Energy density: nr
Uçar et al., 2022 (Turkey) ^[31][31] Uçar G., Elbay Ü.Ş., Elbay M. Effects of low-level laser therapy on injection pain and anesthesia efficacy during local anesthesia in children: a randomized clinical trial. Int J Paediatr Dent. 2022;32(4):576-84.	Split-mouth	60 (30♀, 30♂) 60 - Control: topical anesthesia 60 - Test: topical anesthesia + PBMT	7.11 ± 1.12 ^a a Age range. 6 to 9 years old	Cheese Dental Diode Laser (GIGAA LASER, Wuhan Gigaa Optronics Technology Co., China)	Mucosa was properly isolated and dried. Local anesthetic gel (10% lidocaine) was applied for 60 s with cotton. Photobiomodulation was applied at anesthetic puncture for 20 s with slow circular movements and 1-mm away from the surface.	Local anesthesia was performed with 1-mL of anesthetic solution containing 4% articaine hydrochloride with 1:100,000 epinephrine (Ultracaine D-S forte, Hoechst Canada Inc., Montreal Quebec, Canada), a 27-gauge dental needle and a 2-mL plastic disposable dental syringe (Helmed, Adana, Turkey).	WBFPRS and FLACC scales applied immediately after injection in two stages: 1) During needle insertion; 2) During anesthetic solution deposition.
				Wavelength: 810 nm
				Continuous mode
				Power: 300 mW
				Focal spot: 0.087 cm²
				Energy density: 69 J/cm²

Author	Pain assessment tool	Groups (sample size)	Overall pain score ± SD	Main conclusion
Dantas et al. ^[24][24] Dantas E.M., de Carvalho C.M., Batista S.H.B., de Menezes M.R.A., Dantas W.R.M. Efeito antiálgico do laser AsGaAl na punção anestésica. [Analgesic Effect of GaAlAs Laser on Anesthetic Action]. Rev Cir Traumatol Buco-Maxilo-Fac. 2011;11(2):75-82. Portuguese.	10-score VNS	G1 - Laser group (n=20)	1.9 ± nr	PBMT reduced the resulting pain of anesthetic application in the palate region when used before the application.
		G2 - Placebo group (n=20)	2.7 ± nr
		G3 - Control group (n=20)	4.35 ± nr
Sattayut ^[25][25] Sattayut S. Low intensity laser for reducing pain from anesthetic palatal injection. Photomed Laser Surg. 2014;32(12):658-62.	100 mm VAS	G1 - Laser group (n=20)	11 (10‒30)^c c Median; (number - number) ‒ confidence interval.	There were no statistically significant differences in pain scores among groups.
		G2 - Local anesthetic gel group (n=20)	23 (18‒39)^c c Median; (number - number) ‒ confidence interval.
		G3 - Pressure group (n=20)	27 (12‒35)^c c Median; (number - number) ‒ confidence interval.
		G4 - Light touch group (n=20)	31 (13‒38)^c c Median; (number - number) ‒ confidence interval.
Ghaderi et al. ^[26][26] Ghaderi F., Ghaderi R., Davarmanesh M., Bayani M., Moghadam S.A. Pain management during needle insertion with low level laser. Eur J Paediatr Dent. 2016;17(2):151-4.	100 mm VAS	G1 - Laser group (n=66)^a a Split-mouth sample.	21 ± 2.9	PBMT was not effective in decreasing pain perception due to needle insertion into the maxillary buccal mucosa.
	100 mm VAS	G2 - Placebo group (n=66)^a a Split-mouth sample.	19 ± 2.7
Tuk et al. ^[27][27] Tuk J.G.C., van Wijk A.J., Mertens I.C., Keleş Z., Lindeboom J.A.H., Milstein D.M.J. Analgesic effects of preinjection low-level laser/light therapy (LLLT) before third molar surgery: a double-blind randomized controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;124(3):240-7.	11-point NRS	G1 - Laser group (n=83)	5.2 ± 2.4	PBMT did not effectively decrease pain during local anesthetic injections before third molar surgery.
	11-point NRS	G2 - Placebo group (n=80)	4.8 ± 2.2
Jagtap et al. ^[28][28] Jagtap B., Bhate K., Magoo S., Santhoshkumar N.S., Gajendragadkar K.S., Joshi S. Painless injections-a possibility with low level laser therapy. J Dent Anesth Pain Med. 2019;19(3):159-65.	10-score VAS	G1 - Laser group (n=25)^a a Split-mouth sample.	2.8 ± 0.866	PBMT reduced pain during injection of local anesthesia.
	10-score VAS	G2 - Placebo group (n=25)^a a Split-mouth sample.	7.12 ± 1.301	PBMT reduced pain during injection of local anesthesia.
Ghabraei et al. ^[29][29] Ghabraei S., Bolhari B., Nashtaie H.M., Noruzian M., Niavarzi S., Chiniforush N. Effect of photobiomodulation on pain level during local anesthesia injection: a randomized clinical trial. J Cosmet Laser Ther. 2020;22(4-5):180-4.	170 mm VAS	G1 - Laser group (n=22)	88.1 ± 34.5	PBMT significantly reduced the local anesthesia injection pain in the anterior maxillary region without superiority over placebo irradiation.
		G2 - Placebo group (n=22)	95 ± 33.4
		G3 - Control group (n=12)	101.1 ± 22
Amruthavarshini et al. ^[30][30] AmruthaVarshini I., Vinay C., Uloopi K.S., RojaRamya K.S., Chandrasekhar R., Penmatsa C. Effectiveness of pre-cooling the injection site, laser biostimulation, and topical local anesthetic gel in reduction of local anesthesia injection pain in children. Int J Clin Pediatr Dent. 2021;14(1):81-3.	WBFPRS	G1 - Laser group (n=30)^b b Crossover sample.	2.13 ± 1.66	PBMT was less effective than the other two techniques.
		G2 - Ice group (n=30)^b b Crossover sample.	1.13 ± 1.36
		G3 - Local anesthetic gel group (n=30)^b b Crossover sample.	1.27 ± 1.34
	SEM scale	G1 - Laser group (n=30)^b b Crossover sample.	1.67 ± 0.61
		G2 - Ice group (n=30)^b b Crossover sample.	1.07 ± 0.25
		G3 - Local anesthetic gel group (n=30)^b b Crossover sample.	1.23 ± 0.43
Uçar et al. ^[31][31] Uçar G., Elbay Ü.Ş., Elbay M. Effects of low-level laser therapy on injection pain and anesthesia efficacy during local anesthesia in children: a randomized clinical trial. Int J Paediatr Dent. 2022;32(4):576-84.	WBFPRS	G1 - Needle insertion in laser group (n=60)^b b Crossover sample.	0.82 ± 0.83	PBMT showed significantly better results only using the Wong-Baker Faces Pain Rating Scale.
		G2 - Needle insertion in control group (n=60)^b b Crossover sample.	1.23 ± 0.92
		G3 - Anesthetic deposition in laser group (n=60)^b b Crossover sample.	0.82 ± 0.83
		G4 - Anesthetic deposition in control group (n=60)^b b Crossover sample.	1.23 ± 0.92
	FLACC scale	G1 - Needle insertion in laser group (n=60)^b b Crossover sample.	0.67 ± 0.6
		G2 - Needle insertion in control group (n=60)^b b Crossover sample.	0.8 ± 0.66
		G3 - Anesthetic deposition in laser group (n=60)^b b Crossover sample.	0.67 ± 0.6
		G4 - Anesthetic deposition in control group (n=60)^b b Crossover sample.	0.78 ± 0.67

GRADE assessment
Number of studies (participants)	Summary of findings	Certainty
*PBMT versus Placebo (Adults)*
5 (344 participants)	Four studies did not find any statistical difference between placebo and PBMT, one study found better results for the PBMT group.	⨁⨁ Low^a a Risk of bias ‒ One or more studies presented a high risk of bias. ,^b b Imprecision ‒ Few participants (<400) - downgraded by one level.
*PBMT plus topic anesthetic versus Topic anesthetic (Adults)*
1 (66 participants)	The study did not find significant differences between groups.	⨁ Very low^a a Risk of bias ‒ One or more studies presented a high risk of bias. ,^c c Imprecision - Very few participants (<100) ‒ downgraded by two levels. ,^d d Inconsistency was not assessed because there was only one study included. GRADE Working Group grades of evidence High certainty: Very confident that the true effect is close to the estimated effect. Moderate certainty: Moderately confident in the estimated effect: The true effect is likely close to the estimated effect, but it may be substantially different. Low certainty: Limited confidence in the estimated effect: The true effect may be substantially different from the estimated effect. Very low certainty: Very little confidence in the estimated effect: The true effect may be substantially different from the estimated effect.
*PBMT plus topic anesthetic versus Topic anesthetic (Children)*
1 (60 participants)	The study showed significantly better results for the PBMT group only using the Wong-Baker Faces Pain Rating Scale.	⨁⨁ Low^c c Imprecision - Very few participants (<100) ‒ downgraded by two levels. ,^d d Inconsistency was not assessed because there was only one study included. GRADE Working Group grades of evidence High certainty: Very confident that the true effect is close to the estimated effect. Moderate certainty: Moderately confident in the estimated effect: The true effect is likely close to the estimated effect, but it may be substantially different. Low certainty: Limited confidence in the estimated effect: The true effect may be substantially different from the estimated effect. Very low certainty: Very little confidence in the estimated effect: The true effect may be substantially different from the estimated effect.
*PBMT versus Topic anesthetic (Adults)*
1 (80 participants)	The study did not find significant differences between the groups.	⨁⨁ Low^c c Imprecision - Very few participants (<100) ‒ downgraded by two levels. ,^d d Inconsistency was not assessed because there was only one study included. GRADE Working Group grades of evidence High certainty: Very confident that the true effect is close to the estimated effect. Moderate certainty: Moderately confident in the estimated effect: The true effect is likely close to the estimated effect, but it may be substantially different. Low certainty: Limited confidence in the estimated effect: The true effect may be substantially different from the estimated effect. Very low certainty: Very little confidence in the estimated effect: The true effect may be substantially different from the estimated effect.
*PBMT versus Topic anesthetic (Children)*
1 (30 participants)	PBMT group presented significantly higher pain scores.	⨁ Low^c c Imprecision - Very few participants (<100) ‒ downgraded by two levels. ,^d d Inconsistency was not assessed because there was only one study included. GRADE Working Group grades of evidence High certainty: Very confident that the true effect is close to the estimated effect. Moderate certainty: Moderately confident in the estimated effect: The true effect is likely close to the estimated effect, but it may be substantially different. Low certainty: Limited confidence in the estimated effect: The true effect may be substantially different from the estimated effect. Very low certainty: Very little confidence in the estimated effect: The true effect may be substantially different from the estimated effect.

[1] * Corresponding author. E-mail address:paranhos.lrp@gmail.com (L.R. Paranhos)

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Effect of photobiomodulation therapy on pain perception during anesthetic puncture of dental local anesthesia: A systematic review

Highlights

Abstract

Background

Material and methods

Results

Conclusion