Supplemental Injection Techniques Advantages Disadvantages

1. There is no anesthesia of 1. Proper needle placement

Intraosseous Anesthesia the lip, tongue, and other is difficult to achieve in some
 Involves the deposition of local anesthetic solution into soft tissues, thus facilitating areas (e.g., distal to the
the cancellous bone that supports the teeth. treatment in multiple second or third molar).
quadrants during a single 2. Leakage of local anesthetic
 The PDL injection (also known as the intraligamentary appointment. solution into the patient’s
injection) was originally described as the peridental 2. Minimum dose of local mouth produces an
injection. anesthetic necessary to unpleasant taste.
achieve anesthesia (∼0.2 mL 3. Excessive pressure or
Other Common Names per root). overly rapid injection may
 Peridental (original name) injection, intraligamentary 3. An alternative to partially break the glass cartridge.
injection. successful regional nerve 4. A special syringe may, on
block anesthesia. occasion, be necessary.
Nerves Anesthetized 4. Rapid onset of profound 5. Excessive pressure can
 Terminal nerve endings at the site of injection and at pulpal and soft tissue produce focal tissue damage.
the apex of the tooth. anesthesia (30 seconds). 6. Postinjection discomfort
5. Less traumatic than may persist for several days.
Areas Anesthetized conventional block 7. The potential for extrusion
 Bone, soft tissue, and apical and pulpal tissues in the injections. of a tooth exists if excessive
area of injection. 6. Well suited for procedures pressure or volumes are
in children, extractions, and used.
periodontal and endodontic
single-tooth and multiple
quadrant procedures

Positive Aspiration
 Zero percent.

Alternative
 Supraperiosteal injection for the entire maxilla and
mandibular incisor region. The infiltration of articaine
hydrochloride in the mandibular molar region has a
significantly high success rate.
Indications Contraindications
Technique
1. Pulpal anesthesia of one or 1. Infection or inflammation
1. A 27-gauge short needle is recommended.
two teeth in a quadrant at the site of injection
2. Treatment of isolated 2. Patients who requires
2. Area of insertion: long axis of the tooth to be treated
teeth in two mandibular “numb” sensation for their
on its mesial or distal root (one-rooted tooth) or on the
quadrants psycho
mesial and distal roots (of a multirooted tooth)
(to avoid bilateral IANB) logical comfort
interproximally.
3. Patients for whom residual
soft tissue anesthesia is
3. Target area: depth of the gingival sulcus. The needle is
undesirable
wedged between the root of the tooth and the interproximal
4. Situations in which
bone.
regional block anesthesia is
contraindicated
4. Landmarks:
5. As a possible aid in the
a. Root(s) of the tooth.
diagnosis of pulpal
b. Periodontal tissues.
discomfort
6. As an adjunctive technique
5. Orientation of the bevel: although not significant to the
after nerve block anesthesia
success of the technique, it is recommended that the
if partial anesthesia is
bevel of the needle face toward the root to permit easy
present
advancement of the needle in an apical direction.

6. Procedure:
a. Assume the correct position (this differs significantly
with PDL injections for different teeth). Sit comfortably, have
adequate visibility of the injection site, and
maintain control over the needle. It may be necessary to
bend the needle to achieve the proper angle, especially h. If the tooth is multirooted, remove the needle and repeat
on the distal aspects of second and third molars.a the procedure on the other root(s).

b. Position the patient supine or semisupine, with the head

turned to maximize access and visibility. Signs and Symptoms
1. Subjective: There are no signs that absolutely assure
c. Stabilize the syringe and direct it along the long axis of adequate anesthesia; the anesthetized area is quite
the root to be anesthetized. If possible, use a mouth mirror circumscribed. When the following two signs are present,
to minimize the risk of accidental needlestick injury there
to the administrator. is an excellent chance that profound anesthesia is present:
a. Ischemia of soft tissues at the injection site.
i. The bevel faces the root of the tooth. b. Significant resistance to injection of solution (with a
ii. If interproximal contacts are tight, the syringe should be traditional syringe).
directed from the lingual or buccal surface of the tooth but
maintained as close to the long axis as possible. 2. Objective: use of a freezing spray (e.g., Endo-Ice) or an
iii. Stabilize the syringe and your hand against the electric pulp tester (EPT) with no response from the
patient’s teeth, lips, or face. tooth with maximal EPT output (80/80).

d. With the bevel of the needle on the root, advance the

needle apically until resistance is met. Safety Feature
 Intravascular injection is extremely unlikely to occur.
e. Deposit 0.2 mL of local anesthetic solution in a minimum of
20 seconds.
Precautions
i. When using a conventional syringe, note that the 1. Keep the needle against the tooth to prevent overinsertion
thickness of the rubber stopper in the local anesthetic into soft tissues on the lingual aspect.
cartridge is equal to 0.2 mL of solution. This may be 2. Do not inject anesthetic solution too rapidly (minimum
used as a gauge for the volume of local anesthetic to 20 seconds for 0.2 mL).
be administered. 3. Do not inject too much solution (0.2 mL per root
retained within tissues).
ii. With a PDL syringe, each squeeze of the “trigger” 4. Do not inject anesthetic solution directly into infected or
provides a volume of 0.2 mL. highly inflamed tissues.

f. There are two important indicators of success of the

injection: Failures of Anesthesia
1. Periapical infection. The pH and vascularity changes at
i. Significant resistance to the deposition of local anesthetic the apex and periodontal tissues minimize the effectiveness
solution. This is especially noticeable when the of the local anesthetic. Use of the PDL injection is
conventional syringe is used; resistance is similar to that not contraindicated in the presence of apical disease, but
felt with the nasopalatine injection and is thought to be its success may be minimized.
the reason for reports of PDL injections being painful. 2. Solution not retained. In this case, remove the needle
The local anesthetic should not flow back into and reenter at a different site(s) until 0.2 mL of local
the patient’s mouth. If this happens, repeat the injection at anesthetic is deposited and retained in the tissues.
the same site but from a different angle. Two tenths of a 3. Each root must be anesthetized with approximately 0.2
milliliter of solution must be deposited and must remain mL of solution.
within the tissues for the PDL to be effective. Meechan26 has
suggested, as a means of preventing leakage of the Complications
anesthetic into the patients mouth on withdrawal of the 1. Pain during insertion of the needle.
needle, that the needle be left in the PDL injection site for Cause 1: the needle tip is in soft tissues. To correct this,
approximately 10 seconds after deposition of the local keep the needle against tooth structure.
anesthetic to permit the drug to diffuse into bone. Cause 2: the tissues are inflamed. To correct this, avoid
use of the PDL technique or apply a small amount of
ii. Ischemia of the soft tissues adjacent to the injection topical anesthetic for a minimum of 1 minute before
site. (This is noted with all local anesthetic solutions injection.
but is more prominent with vasoconstrictor-containing local
anesthetics.) 2. Pain during injection of solution.
Cause: too rapid injection of local anesthetic solution. To
correct this, slow down the rate of injection to a minimum 20
g. If the tooth has only one root, remove the syringe from seconds for a 0.2 mL solution, regardless of
the tissue and cap the needle. Dental treatment may the syringe being used.
usually start within 30 seconds.
3. Postinjection pain.
Cause: too rapid injection, excessive volume of solution, too
many tissue penetrations. (The patient usually complains of
soreness and premature contact
when occluding.) To correct this, manage the pain
symptomatically with warm saline rinses and mild
analgesics, if necessary (usually resolves within 2 to
3 days).

Other Common Names

 Crestal anesthesia.

Nerves Anesthetized
 Terminal nerve endings at the site of injection and in
adjacent soft and hard tissues.

Areas Anesthetized
 Bone, soft tissue, root structure in the area of injection .

Indication
When both pain control and hemostasis are desired for soft
tissue and osseous periodontal treatment or for minor
restorative procedures on mandibular posterior teeth.

Contraindication
Infection or severe inflammation at the injection site.

Advantages
1. Lack of lip and tongue anesthesia (appreciated by most
patients)
2. Minimum volumes of local anesthetic necessary
3. Minimized bleeding during the surgical procedure
4. Atraumatic
5. Immediate onset of action (<30 seconds)
6. Few postoperative complications
7. Useful on periodontally involved teeth (avoids infected
pockets)

Disadvantages
1. Multiple tissue punctures may be necessary.
2. Bitter taste of the anesthetic drug (if leakage occurs).
3. Relatively short duration of pulpal anesthesia; limited
area of soft tissue anesthesia (may necessitate reinjection).
4. Clinical experience necessary for success.

Intraseptal injection
 Useful in providing osseous and soft tissue anesthesia
and hemostasis for periodontal curettage, and surgical
flap procedures, as well as minor restorative procedures
Positive Aspiration
in mandibular posterior teeth.
Zero percent.

Alternatives
1. PDL injection in the absence of infection or severe
periodontal involvement
2. Intraosseous anesthesia
3. Regional nerve block with local infiltration for hemostasis
Technique Safety Feature
1. A 27-gauge short needle is recommended. Intravascular injection is extremely unlikely to occur.
2. Area of insertion: center of the interdental papilla adjacent
to the tooth to be treated.
3. Target area: center of the interdental papilla adjacent to Precautions
the tooth to be treated. 1. Do not inject anesthetic solution into infected tissue.
4. Landmarks: papillary triangle, about 2 mm below the 2. Do not inject anesthetic solution rapidly (not faster than
tip, equidistant from adjacent teeth. 20 seconds).
5. Orientation of the bevel: not significant, although Saa 3. Do not inject too much solution (0.4 mL per site).
doun and Malamed recommend toward the apex.
6. Procedure:
a. Assume the correct position, which varies significantly Failures of Anesthesia
from tooth to tooth. The administrator should be 1. Infected or inflamed tissues. Changes in tissue pH minimize
comfortable, have adequate visibility of the injection site, the effectiveness of the local anesthetic.
and maintain control over the needle. 2. Solution not retained in tissue. To correct this, advance
b. Position the patient supine or semisupine with the head the needle further into the septal bone and readminister
turned to maximize access and visibility. 0.4 mL.
c. Prepare tissue at the site of penetration:
i. Dry it with sterile gauze.
ii. Apply topical antiseptic (optional). Complication
iii. Apply topical anesthetic for minimum of 1 minute.  Postinjection pain is unlikely to develop
d. Stabilize the syringe and orient the needle correctly. If  Not having discomfort and incapacitation often
possible, use a mouth mirror to mini experienced with IANB anesthesia.
mize the risk of accidental needle stick injury to the
administrator.
i. Frontal plane: 45 degrees to the long axis of the Duration of Expected Anesthesia
tooth.  Crestal anesthesia to be approximately 23 minutes,
ii. Sagittal plane: at a right angle to the soft tissue. compared with 32 minutes for the IANB
iii. Bevel facing the apex of the tooth.
e. Slowly inject a few drops of local anesthetic as the needle
enters soft tissue and advance the needle until contact
with bone is made.
f. While applying pressure to the syringe, push the needle
slightly deeper (1 to 2 mm) into the interdental
septum.
g. Deposit 0.4 mL of local anesthetic in not less than 20
seconds.
i. With a conventional syringe, the thickness of the
rubber plunger is equivalent to 0.2 mL.
h. Two important items indicate success of the intraseptal
injection:
i. Significant resistance to the deposition of solution.
a. This is especially noticeable when a conventional syringe is
used. Resistance is similar to
that felt with nasopalatine and PDL injections.
b. Anesthetic solution should not come back into
the patient’s mouth. If this occurs, repeat the
injection with the needle slightly deeper. Intrapulpal Injection
ii. Ischemia of soft tissues adjacent to the injection site  The intrapulpal injection provides pain control through
(although noted with all local anesthetic solutions, both the pharmacologic action of the local anesthetic and
this is more prominent with local anesthetics containing a applied pressure. This technique may be used once the pulp
vasoconstrictor). chamber is exposed surgically or pathologically.
i. Repeat the injection as needed during the surgical
procedure. Other Common Names
None.
Signs and Symptoms
1. As with the PDL injection, no objective symptoms Nerves Anesthetized
ensure adequate anesthesia. The anesthetized area is too Terminal nerve endings at the site of injection in the pulp
circumscribed. chamber and canals of the involved tooth.
2. Subjective: ischemia of soft tissues is noted at the injection
site. Areas Anesthetized
3. Subjective: resistance to the injection of solution is felt. Tissues within the injected tooth.
Indication into the tooth itself, not into soft tissues. In addition,
When pain control is necessary for pulpal extirpation or 25- and 27-gauge needles rarely break.
other endodontic treatment in the absence of adequate Retrieval is relatively simple if the needle breaks.
anesthesia following repeated attempts with other 6. When the intrapulpal injection is performed properly,
techniques. a brief period of sensitivity (ranging from mild to very
painful) usually accompanies the injection. Pain relief
Contraindication usually occurs immediately thereafter, permitting
None. The intrapulpal injection may be the only local instrumentation to proceed atraumatically.
anesthetic technique available in some clinical situations. 7. Instrumentation may begin approximately 30 seconds
after the injection is given.

Advantages
1. Lack of lip and tongue anesthesia (appreciated by most Signs and Symptoms
patients) 1. As with PDL, intraseptal, and intraosseous injections,
2. Minimum volumes of anesthetic solution necessary no subjective symptoms ensure adequate anesthesia. The
3. Immediate onset of action area is too circumscribed.
4. Very few postoperative complications 2. Objective: the endodontically involved tooth may be
Disadvantages treated painlessly.
1. Traumatic: the intrapulpal injection is associated with a
brief period of pain as anesthetic is deposited.
2. Bitter taste of the anesthetic drug (if leakage occurs). Safety Features
3. Relatively short duration of action (15 to 20 minutes).56 1. Intravascular injection is extremely unlikely to occur.
4. May be difficult to enter certain root canals (bending of 2. Small volumes of anesthetic are administered.
the needle may be necessary). Precautions
5. A small opening into the pulp chamber is needed for 1. Do not inject anesthetic into infected tissue.
optimum effectiveness. Large areas of decay make it 2. Do not inject anesthetic rapidly (not <20 seconds).
more difficult to achieve profound anesthesia with the 3. Do not inject too much solution (0.2 to 0.3 mL).
intrapulpal injection.

Failures of Anesthesia
Positive Aspiration 1. Infected or inflamed tissues. Changes in tissue pH
Zero percent. minimize the effectiveness of the anesthetic. However,
intrapulpal anesthesia invariably works to provide effective
pain control.
Alternatives 2. Solution not retained in tissue. To correct this, try to
Intraosseous injection. However, when intraosseous injection advance the needle farther into the pulp chamber or root
fails, intrapulpal injection may be the only viable alternative canal, and readminister 0.2 to 0.3 mL of anesthetic drug.
to provide clinically adequate pain control.

Complication
 Discomfort during the injection of anesthetic. The
Technique patient may experience a brief period of intense
1. Insert a 25- or 27-gauge short or long needle into the discomfort as the injection of the anesthetic drug is
exposed pulp chamber or the root canal as needed. started. Within a second (literally), the tissue is
2. Ideally, wedge the needle firmly into the pulp chamber anesthetized and the discomfort ceases. The prior
or root canal. Occasionally the needle does not fit snugly administration of inhalation sedation (nitrous oxide and
into the canal. In this situation the anesthetic can be oxygen) can help minimize or alter the feeling
deposited in the chamber or canal. Anesthesia in this case experienced.
is produced only by the pharmacologic action of the local
anesthetic; there is no pressure anesthesia.
3. Deposit anesthetic solution under pressure. A small Duration of Expected Anesthesia
volume of anesthetic (0.2 to 0.3 mL) is necessary for  The duration of anesthesia is variable after intrapulpal
successful intrapulpal anesthesia if the anesthetic remains injection, usually between 15 and 20 minutes. In most
within the tooth. In many situations, the anesthetic simply instances the duration is adequate to permit atraumatic
flows back out of the tooth into the aspirator (vacuum) tip. extirpation of the pulpal tissues.
4. Resistance (back pressure) to injection of the drug should
be felt and is important for the success of the injection.
5. Bend the needle, if necessary, to gain access to the pulp
chamber (Fig. 15.17). Although there is an increased risk
of breakage with a bent needle, this is not a problem during
intrapulpal anesthesia, because the needle is inserted