208 Endodontics

9
TheUseofAnesthesiainEndodontics
ARNALDOCASTELLUCCI,KIRKA.COURY

Inachievingtheeliminationofpainduringdentalprocedures,andinparticularendodontictherapiesofvital teeth, it is necessary to use anesthetic solutions.

Byblockingthetransmissionofnerveimpulses,they
makeitpossibletocarryoutsuchtherapiesbyputting
thepatientateaseandthuspermittingthedentistto
operateoptimally.
Very frequently, the patient anticipates endodontic
treatmentwithgreatanxiety.Whatismostfrightening
isthefearofexperiencingpain.Itisthedentistsresponsibilitytocalmthepatientandelicitthemaximal
cooperation by successful anesthesia. Nonetheless,
onemustnotabuseanestheticsastranquillizers.Ifthe
planned treatment is deinitely painless, such as the
cleaningandshapingofanecroticrootcanalorthe
illingprocedureofacanal,itisperfectlyuseless,if
notinfactcontraindicated,toadministeranesthetics.
Thereareseveralreasonsforthis.Inthecaseofthe
necrotic tooth, the preparation of the access cavity
correspondstotheveryimportantcavitytest,andif
oneisworkingunderanesthesia,onemayrealizetoo
latethatalesionthatoriginallyseemedtobeofendodonticoriginwasratherofperiodontalorigin,and
thusthatthepulpwasvital.Furthermore,ifoneuses
anestheticswhennotindicated,oneexcludestheadmittedlyminimalandnotalwaysreliablecollaboration
ofthepatient.
Thedentisthasmanytechniquesavailableforcontrollingpain:topicalanesthesia,localanesthesia,regional
anesthesiaornerveblocks,andotherso-calledsupplementalformsofanesthesia.

whichtopicalanesthesiaisadministeredareliquids,troches,gels(Fig.9.1),sprays,41andcooling20(Fig.9.2).
This type of anesthesia is indicated for desensitizing
themucosatoneedlepricks,whichwouldbenecessaryforlocaliniltration.

Fig.9.1.Ananestheticgelisappliedtopicallytothemucosa,whereittakeseffectafter20-30seconds.

TOPICALANESTHESIA
Topical anesthesia refers to the topical application of
anestheticsforvariousreasons,suchasrenderinglocalizedareasofmucosainsensible.Theprincipalmeansby

Fig. 9.2. An ice stick achieves anesthesia by cooling the palatal

mucosa.Thisallowspainlessintroductionoftheneedle.

9-TheUseofAnesthesiainEndodontics 209

LOCALINFILTRATION
Local iniltration may be deined as a technique by
whichananestheticsolutionisdepositedwithinthe
treatmentarea.30Thistechniquepermitsrapid,eficaciousanesthesiaforallthemaxillaryteethandmandibularincisors.Theneedleisintroducedvestibularlyat
themucogingivaljunctionattheleveloftheaffected
tooth.Ashortneedleisusedtoinjectatleast2ccof
anestheticsolutionintotheregionoftheapices.33
Malamed31recommendsthatlocalanesthesiabeperformed with a single injection. He suggests depositingthesolutionabovetheperiostiumandthentaking
advantageofitscapacitytodiffusethroughtheperiostiumitselfandthecancellousbone.Thisblocksthe
small nerve endings of the affected area. His is therefore a submucosal and supraperiosteal anesthesia
(Fig. 9.3). In contrast, Bence2 recommends that localiniltrationbeperformedintwosteps.First,about
one-ifth of the anesthetic vial is injected above the
periostium,thusanesthetizingthisstructure.Inthesecondstep,thesyringeneedleisintroducedmoredeeplyuntilitencountersbone,afterwhichitisdirected
apically, below the periostium, as close as possible
to the apex of the tooth being treated. The remainderofthevialistheninjected(Fig.9.4).Theanestheticshouldbeinjectedslowlyandonlyaftertheperio-

Fig. 9.3. Submucosal and supraperiosteal anesthesia.

stiumhasbeenanesthetized,becauseitispainful.The
periostiumlimitsthediffusionoftheanesthetic;inaddition, the resulting compression facilitates the absorptionoftheanestheticbythebone.
Completepulpanesthesiaisthusattainedinjustafew
minutes.Inthetimeitrequirestoplacetherubberdam,
thedegreeofanesthesiareachesthedesiredlevel.
Toanesthetizethenerveibersthatinnervatethepalatalrootoftheuppermolarsorpremolars,oranyother
tooththathasapalatalroot,itisadvisabletoperform
apalataliniltrationafterthevestibulariniltration(Fig.
9.5). The palatal root is usually closer to the palatal
thanvestibularcorticalbone;thus,abuccaliniltration
alonemaynotsufice.
Toperformapalataliniltration,itisnotnecessaryto
reachtheperiostium.Thepalatalmucosaissoadherentandthickthatitisabletolimitthediffusionofthe
anestheticandforcethesolutionintotheunderlying
bone,liketheperiostiumofthevestibularside.
Palataliniltrationisquitepainful.Therefore,itshould
be performed slowly by steadily depositing a small
amountofanesthetic(0.5ml)underadequatepressure.Beforeperformingthepalataliniltration,itisadvisabletoachieveanesthesiaofthemucosa,forexamplebycooling.20
AsalreadydescribedinChapter8,specialprecaution
isrequiredforiniltrationofthemucosaoverlyingthe

Fig.9.4.Subperiostealanesthesia.

Fig.9.5.Teethwithpalatalrootsrequireapalataliniltrationtoo.

210 Endodontics

purulentcollectionofanacutealveolarabscess,beforemakinganincisionfordrainage.Theneedleshould
not penetrate the purulent collection, but should be
introducedtangentiallytothemucosaandshouldbe
visiblethroughthetransparencyofthetissues,creatingarapidischemiceffect.Theuseofanestheticsolutionwithvasoconstrictorisadvisable(Fig.9.6).

Inferioralveolarnerveblock
Thisisusuallycalledmandibularnerveblock.Itservestoanesthetizeallthemandibularnervesofthesamequadrant.However,becausethelowercentralincisorsmaybeinnervatedbythecontrolateralhemiarch,
itispreferabletoanesthetizethembyavestibulariniltrationtoobtainmorecertainresults.
Adequate anesthesia is indicated by tingling and
numbnessofthelowerlipand,whenthelingualnerve is affected, the tip of the tongue. This technique
does not achieve anesthesia of the vestibular mucosaorperiostiumassociatedwiththemolars,whichare
innervated by the buccinator nerve. One must keep
this in mind if one must intervene surgically in this
area.Anesthesiaofthebuccinatornerveisperformed
by inserting the needle into the mucosa distal and
buccaltothelastmolar.
To anesthetize the inferior alveolar nerve with this
technique,theanestheticsolutionmustbedeposited
inthevicinityofthenervebeforeitentersthemandibularramusatthelevelofthemandibularspine.
Eithertheindirectordirecttechniquemaybeused.

Indirecttechnique

Fig.9.6.Anesthesiaofthemucosaoverlyingthepurulentcollection,beforetheincisionfordrainage.

REGIONALANESTHESIAORNERVEBLOCKS
Regionalanesthesiaornerveblockinvolvesalarger
area than the forms of anesthesia discussed above;
however,itmorepreciselyanesthetizestheentiredistributionofaspeciicnerve.Itisachievedbydepositingthelocalanestheticnearthetrunkofamajornerve,thusblockingtheafferentimpulsesfromtravelling
proximaltothatpoint.
Thesuccessofthismethoddependsonthedentists
precision in depositing the anesthetic solution at a
pre-selectedanatomicalpoint.Theanestheticdiffuses
from this point in suficient amounts and concentrationstoproducethedesiredeffect.41
Blockoftheinferioralveolarnervewillbediscussed
indetail,whiletheothernerveblocksofdentalinterestwillreceivebrieferattention.

The indirect technique is performed with a long

needle.Theneedleisdirectedtowardtheramus,starting from the controlateral molars, until it encountersbone.Theneedleisthenwithdrawnslightly,redirectedparalleltothehemiarchtobeanesthetized,
andinsertedmoredeeply.Onceitcontactsthebone,
theneedleisinsertedslowlyalongthemedialsurface
ofthemandibularramus,forabout2cm(Fig.9.7).
With this technique, the onset of anesthesia is oftenslow,andtheinexactinsertionoftheneedlemay
produceanesthesiainother,unintended,areas.Ifthe
needleisintroducedtoosupericially,theanesthesia
will affect only the lingual nerve; if introduced too
deeply,itmayanesthetizethefacialnerve.

Directtechnique
The aforementioned drawbacks are usually avoided
bytheuseofthedirecttechnique,whichisassociated
withamuchquickeronsetofaction.Ashortneedle
isusedtopenetrateascloseaspossibletothemandibularspine(Fig.9.8).Withthepatientsmouthwide
open,thedentistplacesthethumbintothepatients

9-TheUseofAnesthesiainEndodontics 211

Fig.9.7.A-F.Blockoftheinferioralveolarnerve,usingalongneedleandtheindirecttechnique.

B
Fig.9.8.A,B.Blockoftheinferioralveolarnerve,usingashortneedleandthedirecttechnique.

212 Endodontics

mouthtoidentifytheanteriorborderofthemandibular ramus (Fig. 9.9). The middle inger supports the

posteriorborder,outsidethemouth(Fig.9.10).
Withthesyringedirectedalonganimaginarylinepassingabovethecontrolateralpremolars,onepenetratesthemid-pointbetweenthethumbandmiddleinger, and after aspirating to avoid injecting the anesthetic directly into the circulation, the solution is
injected.Thepointofinsertionoftheneedleisjustlateral to the pterygomandibular raphe, which is midwaybetweenthetwohemiarches,toadepthofabout
1cm.Duringthisprocedure,itisimportanttoaskthe
patienttoremainwideopen.33
Thistypeofanesthesiaistheprincipalmeansofanesthetizingtheteethofthelowerarch,sincelocalanesthesiawouldnotbeeficacious,giventhebonydensityofthemandible.

Mentalnerveblock
Anesthesia of the canine and lower irst premolar
can be achieved at the level of the mental foramen
(Fig.9.11),ratherthanmandibularspine.Thishasthe
advantageoftakingeffectsoonerandavoidinganesthesia of the tongue, thus sparing the patient pointlessparesthesiae.
Itisperformedbydepositingtheanestheticsolution
nearthemandibularcanal,atthelevelofthemental foramen. The needle is inserted in the alveolar
mucosabetweenthetwopremolars,about1cmexternaltothevestibularsurfaceofthemandible(Fig.
9.12).
Particular attention must be paid to not injuring the
mentalnervewiththepointoftheneedle.Itmustnot
beintroducedinthementalforamen.

Fig.9.9.Thethumbisusedtoidentifytheanteriormarginofthe
mandibularramus.

Fig.9.10.Themiddleingerisusedtosupporttheposteriormarginofthemandibularramus.

Fig.9.11.Mentalnerveblock.

Fig. 9.12.To achieve anesthesia at the level of the mental foramen, the needle must be introduced into the alveolar mucosa
betweentheirstandsecondpremolars,about1cmexternalto
thevestibularsurfaceofthemandible.

9-TheUseofAnesthesiainEndodontics 213

Nasopalatinenerveblock

Anteriorpalatinenerveblock

Theinnervationofthesofttissuesoftheanteriorone
thirdofthepalatearisesfromthenasopalatinenerve,
whichemergesfromtheincisiveforamen(Fig.9.13).
Intheregionofthecanine,terminalbranchesofthis
nervearesuperimposedonterminalbranchesofthe
anteriorpalatinenerve.
Anesthesiaisachievedbyintroducingtheneedleinto the palatine surface, next to the incisive papilla,
andinjectingtheanestheticunderpressure(Fig.9.14).
This procedure may be quite painful. However, it is
usually necessary in the case of extractions or other
surgicalproceduresinthisarea.

The innervation of the soft tissues of the posterior

two-thirdsofthehardpalatearisesfromtheanterior
palatine nerve. This nerve emerges from the greater
palatineforamen,whichliesbetweenthesecondand
thirdmolars,half-waybetweenthealveolarcrestand
midlineofthepalate(Fig.9.15).Anesthesiaisachievedbyintroducingtheneedlenearthepointofemergenceofthenervefromtheforamen(Fig.9.16).This
procedureisalsoquitepainfulandisusedforextractionsorsurgicalprocedures,whenanesthesiaofthe
softtissuesofthehardpalatefromthetuberosityto
the region of the canine or from the midline of the
hardpalatetothegingivalmarginisrequired.

Fig.9.13.Courseofthenasopalatine
nerveafteritsemergencefromthe
incisiveforamen.

Fig.9.15.Courseoftheanteriorpalatine nerve after its emergence

fromthegreaterpalatineforamen.

Fig.9.14.A,B.Siteofintroductionoftheneedleinperforminganasopalatinenerveblock.

Fig.9.16.A,B.Siteofintroductionoftheneedleinperformingananteriorpalatinenerveblock.

214 Endodontics

SUPPLEMENTALANESTHETICTECHNIQUES
Applyingthecommonly-usedtechniquesoflocaliniltrationornerveblocktoendodontictherapy,onemay
sometimes encounter problems related to inadequate anesthesia of a tooth. This tipically happens with
lowermolarsaffectedbyirreversiblepulpitis.
Theendodonticallyinvolvedtooththatexhibitssymptoms consistent with an irreversibile pulpitis is perhapsoneofthemostchallengingandfrustratingconditionstomanageintermsofachievingprofoundanesthesia. If mismanaged, the patient will often relate
theexperienceasphysicallyandmentallyagonizing.
Wearemanytimesatadisadvantage.Asifapprehensionisnotenoughtodealwith,whencombinedwith
inlammation40,53theybothacttosigniicantlydecreasethelevelofpainthreshold.10Theconsequencesof
this hypersensitivity to stimuli that ordinarily would
notbeperceivedorinterpretedaspainmayresultin
a marked dificulty in attaining profound anesthesia.
Whileapprehensionisusuallycommoninmostdentalpatientsandcanbemanagedbyavarietyoftechniques,inlammationandinfectioncanpresenttheir
ownkindsofuniquechallengesforthedentistwhen
trying to achieve profound anesthesia to perform
comfortable treatment for the patient. Other known
factorswhichmaycontributetoanestheticcomplicationsincludepatientfatigueandpreviousepisodesof
unsuccessfulanesthesia.64,68

Anestheticsolutionsandinlammation
It is well known that the pH of the local anesthetic solution and the pH of the tissue into which it
is deposited can affect its nerve-blocking action.34
Environmentalchangesinthepulpandperiradicular
tissues during inlammation and/or infection signiicantlyaltersthepHinthetissuessurroundingtheinvolvedtooth,loweringitfromanormalpHofaround
7,4toaslowas5to6inpurulentconditions.34This
hasamarkedinluenceontheeficacyoflocalanestheticsolutions.34
When an anesthetic solution is deposited into areas
of inlammation, the acidic environment decreases
itseffectivenessbyliberatingamuchhigheranestheticconcentrationofthechargedcation(RNH+)relativetouncharged(free)baseform(RN).34Itistheun-

charged,free-baseformthatisresponsibleforpenetratingthenervesheath,therebycreatingthedesired
anestheticeffect.Forexample,injectingananesthetic
solutionwithapKa*of7,9(SeeTableI)intonormal
tissueswouldresultinapproximately75%ofthelocal
anestheticmoleculesinthecationicformand25%in
thefree-baseform.34Withinlammation,adropinpH
results in approximately 99% of the same local anestheticagent(pKaof7,9)tobeinthecationic(charged)form,leavingonlyonepercentofthefree-base
formtopenetrateintothenerve,adverselyaffecting
theanestheticresponse.
OnepossiblewaytoovercometheeffectsoftissuepH
onanestheticsolutionsistodepositagreatervolume
ofanesheticintothearea.Eventually,enoughofthe
unchargedfree-basemoleculeswillbecomeavailable
fornervepenetrationandwillfrequentlybeadequateinachievingthedesiredanestheticeffect.34Another
methodmightbetoregionallyblocktheareabyinjectingintotissuesdistantfromthesiteofinlammation
orinfection.Bydoingso,onecanpresumethatthe
tissuesinthisareahaveamorenormalpHand,therefore,shouldenhancetheanestheticeffect.Forthis
reason,regionalblockscanbeverybeneicialinthe
treatmentofsomeendodonticallyinvolvedteeth.

TableI
Dissociationconstants(pKa)
offrequentlyusedlocalanesthetics

Anesthetic
solution

pKa

a%base
atpH7,4

Approximate
onsetof
action(min)

Mepivacain
Etidocaina
Lidocaina
Prilocaina
Bupivacaina

7,6
7,7
7,9
7,9
8,1

40
33
25
25
18

2to4
2to4
2to4
2to4
5to8

If conventional anesthetic techniques fail to provideeffectiveanesthesia,(i.e.regionalblocksandiniltrations) and proper injection technique was performed,(whichisthemostcommonreasonforanestheticfailure34)thenitmaybeusefultorepeataninjectiononlyifthepatientdoesnotexibittheclassicsigns

(*)pKaaffectstheonset;thelowerequalsmorerapidonsetofaction,moreRNmoleculespresenttodiffusethroughthenervesheath,thusonsettimeisdecreased.34

9-TheUseofAnesthesiainEndodontics 215

ofsofttissueanesthesia.However,iftheanestheticeffectshavebeenconirmed,butthepatientcannottoleratedentinorpulpmanipulation,reinjectionisgenerallyineffective.Thisistheappropriatetimetoconsiderasupplementalanesthetictechnique.68
These types of anesthesia, intraligamental in particular,mayalsobenecessaryinpatientsinwhomtheuse
ofroutineanesthesia,suchasaninferioralveolarnerveblock,iscontraindicated.Thismayapplytopatients
withhemophilia22orotherdisordersofcoagulation,in
whom post-injection bleeding may be dangerous. It
mayalsoapplytomentallyorphysicallyhandicapped
patients,inwhomthereisagreatriskoftraumatizing
softtissuesstillundertheanestheticeffectoftheblock,
suchasthetongueorlowerlip30(Fig.4.1C).
Ina1981studybyWaltonandAbbott,6647%ofteeth
that required supplementary anesthesia were lower
molars.Thismayhavebeenrelatedtotheaccessory
innervationthattheseteethcanreceivefromdifferent
branchesoftheinferioralveolarnerve.14,60
Supplementary anesthesia includes the lingual iniltration,theintraseptalinjection,theperiodontalligament injection, the intrapulpal injection and the intraosseousinjection.

Lingualiniltration
Itisusefulinlowerirstmolarswithpulpitis.Holding
thesyringeparalleltotheocclusalplane,theneedle
is introduced into the lingual gingiva about halfway
betweenthegingivalmarginandthebaseofthefor-

nix(Fig.9.17).Thedevelopmentofawhitishareaof
ischemiaassuresthatthetechniqueiscorrect.If,instead,abubble-likecollectionofanestheticformsin
thelingualfornix,thetechniqueisincorrect.Theapproachmustberepeatedbyinsertingtheneedlemoreocclusally.
Schilder51recommendstheroutineuseoflingualiniltrationeachtimeanendodontictreatmentisperformedonalowermolar.Oncethenerveblockhasbeen
accomplishedwith3/4ofthevial,theremaining1/4
maybeusedtoperformthelingualiniltration,which
in practice is nothing more than a subperiosteal lingualiniltration.

Intraseptalinjection
Described by Bandford1 in 1970 and by Marthaler37
in1973,isaccomplishedatthelevelofthebonyseptumbyintroducingtheneedleintothedentalpapillaandinjectingaminimumamount(0,2-0,4ml),distally to the tooth to be anesthetized.5 Because this
typeofanesthesiamustbeperformeddirectlywithin
thecancellousbone,thedentistmustovercomehigh
pressureswiththeinjection.Forthisreason,theuse
ofanappropriatepressuresyringe,suchasPeripress
(Fig.9.18),isrecommended,togetherwitha27-gaugeshortneedle.
Asforalltheintraosseousinjections,itisadvisableto
useananestheticsolutionwithoutvasoconstrictor,in
ordertoavoidsystemiceffects.
Thisanesthesiaisindicatedwhentheperiodontalin-

Fig.9.18.Peripresspressuresyringe.
A

Fig.9.17.A,B.Subperiosteallingualanesthesia.

216 Endodontics

volvement precludes the use of the intraligamental

injection.Theadvantagesoftheintraseptalanesthesia
areseveral:onlyaminimumvolumeofsolutionisrequired,thereisnolipandtongueanesthesia,immediateonsetofaction(lessthan30seconds)andpresentsveryfewpostoperativecomplications.47Thepulpalanesthesiahasashortduration,andthishastobe
intoconsiderationduringendodontictreatment.

Intraligamentaliniltration
Castagnolaetal.8in1976,WaltonandAbbott66in1981,
andMalamed32in1982havedemonstratedthatinjectionintothespaceoftheperiodontalligamentismost
effective in situations in which the local anesthesia
achievedwithtraditionaltechniquesisincomplete.
Thistypeofanesthesiaisperformedwiththeappropriatesyringe,suchasPeripress,Citoject(Fig.9.19),
or Ligmaject, by introducing the small needle (27gauge) into the space of the periodontal ligament,
makingsurethattheneedlesbevelfacestheboneof
the alveolar crest (Fig. 9.20), according to some authors,23,55,57,65,66 or, according to others,30,35 the root of
the tooth so as not to damage the radicular cementum. According to the author opinion, since the solutionusuallyentersintothebonemarrowspacesratherthanpenetratingintotheperiodontalligament61
theneedlesbevelshouldfacethebone.
The needle must be forced to the point of maximal
penetration,andtheanestheticmustbeinjectedunderhighpressure.
Iftheanestheticsolutionlowsoutofthevialwithout
mucheffortonthepartofthedentist,theneedleis
malpositioned.Itmustbere-positionedandintroduced more deeply. In multirooted teeth, the anesthesiamustberepeatedforeachroot(Fig.9.21),Theindroductionoftheneedleshouldalwaysbeintheinterproximalareas,neveronthebuccal.Theanestheticeffectisimmediateandprolonged.Thesizeofthe
needlehaslittlerelationtotheanestheticeffect.The
manufacturers of pressure syringes recommend very
thin needles (0.30 mm in diameter), but these tend
tobendeasily.Betterresultsareobtainedwithshort,
25/27-gaugeneedles.36,58
Numerous studies have investigated the periodontal
damagecausedbythistypeofanesthesia,whichwas
irstdescribedbyFischer13in1923butfellintodisusebecauseitwasthoughttobedetrimentaltotheperiodontalligament.
Castagnolaetal.8assertthattheyhaveneverfoundthe

Fig.9.19.Citojectsyringeforintraligamentalanesthesia.

Fig.9.20.Someauthorscontendthatthebeveloftheneedlemustfacetheboneofthealveolarcrest.

Fig.9.21.Inmultirootedteeth,intraligamentalanesthesiamustbeperformed
onalltheroots.

sortofdamagethatotherauthorshavefeared,namely
necrosisoftheperiodontalligamentasaresultofthe
actionoftheanesthetic,periodontitisfromtheinoculationofmicrobes,andtraumaticarthritisfromtheinsertionoftheneedle.Norhassuchdamageeverbeen
demonstratedexperimentally;indeed,theclinicalimpressionarisingfromtheuseofthistechniqueisthat
thereisnoirreversibledamagetotheperiodontalligament.70Thisclinicalimpressionisconirmedbyhistologic studies in monkeys67 and dogs.15 These studieshaveshownthattheperiodontalligamentexperiencesonlylimited,reversibleinjury.Thedamageis
coninedtotheregionoftheinjectionandtothezonesimmediatelyadjacenttoit,anditisfollowedby
rapid restitutio ad integrum. Thus, this method of
anesthesiamaybeconsideredinnocuousfortheperiodontium.45,46,52
Contraindications to the intraligamental injection include infection or severe inlammation at the injectionsiteandprimaryteeth.Brannstrometal.7reportedthedevelopmentofenamelhypoplasiainpermanentteeth,followingtheadministrationoftheperiodontalligamentinjection.
In contrast to intrapulpal anesthesia, which is always painful for the patient, intraligamental anesthesia is painless if done after standard anesthesia.
Other advantages of intraligamental anesthesia are
thatitdoesnotrequirespecialequipment.Itmaybe
donewithapressuresyringe,butmayalsobedone
withthesamesyringeandneedleusedforthestandardinjection.
Nevertheless, the use of appropriate syringes is recommended, since they may attain pressures more

Fig.9.22.Iftheneedarises,intraligamentalanesthesiamayalsobeperformed
withtherubberdaminplace.Thereisnoneedtoremovetherubbersheet;it
needsonlybestretchedaside.

9-TheUseofAnesthesiainEndodontics 217

thantwiceashighasregularsyringes.15Furthermore,
sincethevialissheathedinametallicorTeloncontainer,theybetterprotectthepatientagainstaccidentalruptureoftheglassvial,whichcanoccurasaresultofthehighpressuregenerated.Finally,itiseasier
todosetheinjectedanestheticataconsistentvolume
witheachactivationofthesyringe.
Ifitbecomesnecessarytousethistypeofanesthesia
whentherubberdamisalreadyinposition,itisnot
necessarytoremoveorliftit.Theopeningoftherubberdammaybestretchedslightlytoidentifythespaceintowhichtoinserttheneedle(Fig.9.22).
Regardingtheanestheticsolutionsdistributioninthe
tissues, intraligamental anesthesia must be considered to all effects an intraosseous anestesia.36,43,65 The
injected solutions are rapidly absorbed by the systemic circulation55,57 (Figs. 9.23, 9.24). For this reason,
the use of anesthetics containing catecholamines for
intraligamental anesthesia is inadvisable in patients
withischemicheartdiseaseorhypertension.55Inthis
respect, intraligamental anesthesia is identical to intraosseousanesthesia;comparedtothelatter,however, it is easier to perform. In animal experiments,
theeffectsofintraligamentally-administeredvasoconstrictor-containinganestheticsonheartrateandblood

Fig.9.23.Alveolusofthelowerirstmolarinahumanskullafterremovalofthe
tooth.Thecorticalbonehasacribriformappearance,especiallyinthecervical
region,wheretheanestheticpassesintothemedullaryspaces.Thatwhichis
radiographicallydeinedasthelaminaduraisinfactaporousstructure.

218 Endodontics

Intrapulpaliniltration

Fig. 9.24. Schematic representation of the probable path of distribution of a local anesthetic solution injected into the space of the periodontal ligament.

pressurearethesameasthosewhichoccurafterintraosseousorintravenousadministrationofthesame
substances.However,theseeffectsarecompletelyabsentiftherouteofadministrationissubmucosal,intrapulpal,subcutaneous,orintramuscular.43
Therefore,ifweneedtousetheintraligamentalinjectionoranyotherintraosseousanesthesiainapatient
with high blood pressure, cardiovascular disease or
anycontraindicationtoepinephrineuse,itisprudent
tochoose3%mepivacaine,whichhasminimalcardiovascuareffects.16,47,49
As previously reported by Castagnola et al.8 and
Langeland,25Linetal.28havedemonstratedthatintraligamentalanesthesiadoesnotcauseanyhistological
damagetohealthypulptissuesandisthusalsoindicated for procedures other than endodontic ones. It
maythereforebeconidentlyusedasadiagnosticaid
inlocalizingpulpalgiabyselectivelyadministeringthe
anesthetictotheindividualteeth,51thoughsomeauthorshaveexpressedscepticism.11,23,65
Inconclusion,thepreferredsupplementaltechniqueto
obtainprofoundpulpalanesthesiaifthestandardblock
oriniltrationinjectionisnoteffective,atthistimeisthe
periodontalligamentinjection.Ifeventheperiodontal
ligamentinjectiondoesnoteffectprofoundpulpalanesthesia,theintrapulpalinjectionisthenextoption.63

Described by numerous authors,4,18,21,31,39,69 the intrapulpalinjectionassurescertainresultsin100%ofcases.Itrequirestheinjectionofanestheticthroughas

smallanopeningaspossibleintheroofofthepulp
chamber(Fig.9.25).
Thepressurewithwhichtheanestheticsolutionmust
beinjectedisactuallyresponsiblefortheanesthesiceffectofthistechnique.4Infact,thesamedegreeofanesthesiamaybeobtainedbyinjectingsalinesolution.63
Itisimportantthatthechamberopeningbesmalland
that the needle be well engaged. This assures good
pressurewithinthechamberitself.Thepressurethus
transmitted to the pulp tissue causes instantaneous,
profoundanesthesia,evenforveryprolongedendodonticprocedures.Iftheopeningintothepulpchamberistoolargetowedgetheneedle,alargersizeneedlecanbeused.Othertimesitisnecessarytoplace
piecesofrubber,waxorcottonpelletsoveroraround
theneedletoforastopper.63
In multirooted teeth, however, it may be necessary
torepeatthistypeofanesthesiaintheindividualcanals.56Theanesthesiamaybepainful,butthesensitivitywilllastforonlyafewseconds.Itsuficestoinject
afewdropsofanestheticunderpressuretoobtainthe
desiredeffect.31Ifthepulpisnotcompletelyremoved
during the visit, the remaining tissue will remain vi-

Fig.9.25.Intrapulpalanesthesia.

9-TheUseofAnesthesiainEndodontics 219

taluntilsubsequentappointments.Therefore,theanesthesiamustberepeated.4
Some authors38 state that intrapulpal anesthesia can
alsobeusedinthecourseofpulpotomyinteethwith
animmatureapexandvitalpulpcompromisedbycariesortrauma.Thechancesofpreservingthevitality
oftheremainingportionofthepulptissueincreases
whenonelimitsthedepthofpenetrationoftheneedleintothepulptolessthan2mmandwhenoneregulatesthepressureduringtheinjection.
Other authors24 claim that intrapulpal anesthesia
shouldbeavoidedinpulpotomyonteethwithanimmatureapex,sinceitwouldforcecontaminantspresentinthecoronalpulpintotheradicularpulpand
wouldcausealacerationinthetissue.
The intrapulpal anesthesia has no contraindication
andatthesametimeoffersseveraladvantages:lack
oflipandtongueanesthesia,minimumvolumeofsolutionrequired,immediateonsetofaction,nocardiovasculareffectandveryfewpostoperativecomplications.Ontheotherhand,itrequestsasmallopening
intheroofofthepulpchamber.Sometimes,togetthe
littlepulpexposuretoinserttheneedleisverypainfulforthepatientwhoisaskedtocooperate,even
thoughthepreviousanesthesiafailed!
As a precaution, it is not advisable to inject into infectedtissue,toavoidtheriskofspreadingtheinfectionintheperiapicaltissues.36

technique,withalittlepractice,ismoreuser-friendly
andiswelltoleratedbythepatient.Thetechniquehas
shownfavourableresultsinthatitspulpalanesthetic
effectisextremelyrapid,almostimmediate.9Forthis
reason,itisverysuccessfulasasupplementaltechnique,9,12,44anditisparticularlyeffectiveincasesofirreversiblyinlamedpulpsinmandibularmolars.42More
importantly, if performed with care, it can be administered to the patient with little or no discomfort.
Althoughitsuseasaprimarytechniquehasbeensuggested,itsshortduration(15-30minutes)precludesits
useassuchforlengthyendodonticprocedures.9,12,42,48

INTRAOSSEOUSANESTHESIA
Intraosseousanesthesiaisatechniquewherebyteeth
are anaesthetized by injecting local anesthetic solution directly into the cancellous or medullary bone
around the affected tooth.59 Historically, the intraosseous injection was inconvenient and burdensome,
requiringthecliniciantomakeasmall(1.0-3.0mm)
incision,andwithasmall,roundbur,drillorreamer,
penetratethroughthedensecorticalplateofboneintocancellousbone.6,26,29,44Then,withashortneedle,
approximaytely1.0mlofsolutionwasdeposited.The
resultswereveryfavourable,butthetechniqueprovedtediousforthedentistandsomewhatintimidating
for the patient. Currently, two intraosseous systems
areavailablecommarcially(StabidentLocalAnesthesia
System, Fairfax Dental Inc. and X-Tip Intraosseous
AnaesthesiaDeliverySystem,DentsplyMaillefer)that
supply the dentist with a perforator and ultrashort
needles (Fig. 9.26), precluding the need for an incision and the use of a round bur. Consequently, this

Fig.9.26.Perforatorsandultrashortneedles.A.X-Tip.B.Stabident.

Theintraosseoustechnique
As previously mentioned, the intraosseous anesthetic technique is based on the premise that anestheticsolutionisdepositeddirectlyintocancellousbone
adjacenttotheaffectedtooth.Thetechniqueinvolves
threesimplesteps:
1. anesthesiaoftheattachedgingiva
2. corticalboneperforation
3. depositionofanestheticsolutionintocancellousbone.

Step1:anesthetizetheattachedgingiva
Usingtheultrashortneedlesprovidedinthekit,inject
afewdropsofsolutionintotheattachedgingivauntil
slightblanchingoccurs(Fig.9.27).Thiscanbepainlessforthepatientiftheinjectionisslowanddeliberate.Theuseoftopicalanestheticisoptional.Despite

220 Endodontics

Fig.9.27.Anesthetizetheattachedgingival(Spetp1).

Fig.9.28.Generalguidelineforperforationsiteselection.

itsquestionableeffectiveness,itsuse,iffornoother
reason, demonstrates to the patient that every effort is being made to ensure their comfort and well
being.17,50,68

boneinthisareatendstobethinandfragileandtissuenecrosiscouldoccur.Conversely,iftheperforationismadetoofarapically,thebonebecomesthickerandashallowdepthofperforationwouldresultin
aninadequateanaestheticeffect.
The manufacturer suggests injecting distally rather
than mesially whenever possible, because a smaller
dose sufices.59 From personal experience, there has
beennosigniicantdifferencenotedwheninjections
wereperformedmesiallytotheaffectedtooth.Infact,
inthemandibularmolarregion,wherethetechnique
has been most useful, the mesial approach tends to
bemoreaccessible.Itisalsorecommendedthatthe
thinbonebetweenthemaxillaryandmandibularcentralincisorsbeavoided.Shouldtheseteethrequireintraosseous anesthesia, approach the perforation site
distally,orperhapsevenbetter,avoidtousethetechniquealtogetherandrelyoniniltration.

Step2:Corticalplateperforation
The perforator comprises a 27-gauge, solid needle
shankwithabevelledenddesignedtoitintoastandardslow-speed,contra-anglehandpiece.Itis9.0mm
inlengthandcorrespondtothediameterandlength
oftheneedles.Ithasanarrow-diametercollarwhich
provides a safety stop against excessive penetration,
withawiderdiametercollarthatisdesignedtoaidin
preventing debris and lubricant from contaminating
the perforator needle. The perforators are supplied
gamma-raysterilizedandaretobedisposedofafter
patienttreatment.59

Perforatingthecorticalbone
Selectionofinjectionsite
To determine the correct placement for the cortical
penetration,imagineahorizontallinealongthegingivalmarginsoftheteeth,andaverticallinethrough
the papilla. At a point approximately 2.0 mm apical
towheretheselinesintersectisusuallyasuitablesitefortheperforation59(Fig.9.28).Priortoperforating
theplate,itishelpfultorefertothepreoperativeradiographtoassessthespacebetweentherootsofthe
adjacent teeth and to note the relative interproximal
boneheighinthearea.Injectingintosofttissuewill
resultininadequateanesthesia.Caremustbetakento
avoidinjectingtoofarcoronallyintothepapilla.The

Once the site has been selected, and the tissue has
been anaesthetized, place the perforator in a latchtypecontra-angleofaslow-speedhandpieceandremovethesafetycap.Orienttheperforatorperpendicular to the cortical plate at the predetermined site,
andgentlyadvanceitthroughthegingivauntilitrests
irmlyagainstthebone(Fig.9.29).Next,engagethe
motorforapproximatelytwosecondsandapplylight,
intermittentpressureuntilperforationoccurs.Thiswill
beevidentasthesensationcloselyresemblesthegive experienced when accessing the pulp chamber.
Thepatientshouldbeforewarnedofthesensationof
slightvibrationandpressure.

9-TheUseofAnesthesiainEndodontics 221

Fig.9.29.Perforatethecorticalplate(Step2).

Fig.9.30.Inserttheneedleintoperforationsiteandslowlyinject(Step3).

Step3:Injectingintothecancellousbone

tionofanestheticintocancellousbone.
TheAlternativeStabidentguide-sleeveismanuallyinsertedinthedrilledhole(Fig.9.33).Whentheguidesleevehasbeeninsertedintheboneonewayorthe
other,theinjectionneedleisloadedintothefunnelshapedentranceattheotherendoftheguide-sleeve,
toslowlyandgentlyinjectthesolution.
Agoodruleofthumbistoallow60secondspercarpule as a guide to the speed of injection. Usually,

Afterperforationiscompleted,itisimportanttonotetheexactsiteofpenetration.Onesuggestionforits
identiicationistocompressacottonrollagainstthe
mucosaforafewsecondstoabsorbanybloodinthe
area.Oncethepuncturewoundhasbeenisolated,the
chairsideassistantshouldpasstheanestheticsyringe
inapengripfashion,alignandgentlyinserttheneedleintotheperforatingsite(Figs.9.30,9.31).Thismay
takeafewattemptsinitially,butwithexperience,this
phaseofthetechniquebecomeeasier.Ontheother
hand,whenstartingtouseintraosseousanesthesiainitially sometimes can be found some dificulty insertingtheneedleinthedrilledhole.Insuchcasescan
beveryhelpfultouseoftheX-TiportheAlternative
Stabident. In the X-Tip (Fig. 9.32), drilling with the
perforatorautomaticallyplacestheguide-sleeveinpositioninthecorticalbone,toprovideapreciseinjec-

Fig.9.31.Diagramrepresentinglocationforpreparationsiteandinjection.

Fig.9.32.A,B.TheX-Tipleavestheguide-sleeveinpositioninthe
corticalbone(CourtesyofDentsplyMaillefer).

222 Endodontics

B
Fig.9.33.A,B.UsingtheAlternativeStabident,theguide-sleeveismanuallyinsertedinthedrilledhole(CourtesyofFairfaxDentalInc.).

onlyabout0.45to0.90mlor1/4to1/2ofacartrige
isallthatisrequiredtorenderprofoundanesthesia.
However,upto1.8mloronecartrigemustbeused.
Aswithanyinjectionmethod,arapidinluxofthesolution can cause transient discomfort and an increaseinheartrate.12,26,48Itisbesttoalwayspreparethe
patient for this potential consequence before injectionbegins.Astheanestheticisdelivered,theplunger
shouldadvancewithease.Shouldconsiderableforce
berequiredtoinject,assumethateithertheneedleis
notincancellousbone,orisbuttedagainstrootsurface.Ifconsiderablebackpressureismet,attempttorotatetheneedleone-quarterturn.Ifrepeatedattempts
toredirecttheneedleproveunsuccessful,thenchooseanotherpenetrationsiteandrepeatStep2.Inthe
posteriorregionsofthemouth,duetocompromised
access,extremecautionmustbetakentoavoidroot
perforation. For better access into posterior perforationsites,itissometimesbeneicialtobendtheneedleatthehub45degrees.
Beginnersareencouragedtorestrictthemselvestothe
anteriorregionsuntilthesystemhasbeenmastered.
Thisprecautionissuggestedbecausetheangleofperforationrequiredintheposteriorregionsofthemouth
ismorecritical,withagreaterchancefortheoccurrenceofproceduralmishaps,suchasrootperforations
orperforatorandneedlebreakage.

Dosagereccomendations
Absorption of the anesthetic into the blood supply
following intraosseous administration is more rapid
thanwithprimaryinjectiontechniques,thusrequiring
much less to produce the desired anesthetic effects

ascomparedtotraditionalmethods.59Therefore,only
onecartridgeofanestheticperpatientisrecommendedandconcentrationsofvasoconstrictorshouldnot
exceed1:100,000.26,34
Therecommendedanestheticagentforthistechnique
is2%lidocainewith1:100,000epinephrine.68Research
hasshownthat3%mepivacainewithoutepinephrine
doesnotproducethedesiredanestheticeffectwhen
compared to 2% lidocaine with 1:100,000 epinephrine.48

Durationofanesthesia
As with all supplemental injections, the duration of
anesthesiausingtheintraosseoustechniqueisshorter
thanwithstandardiniltrationorblocks.Onecanexpectapproximately15to30minutesofprofoundpulpalanaesthesia.59Thisshouldprovidethepractitioner
withampletimetoaccessthepulpchamberandextirpatethepulpinacomfortable,expedientmanner.

Considerationsforintraosseousanesthesia
Anatomicalconsiderations
Cautionshouldbeexercisedwheninjectingbetween
themandibularpremolarsduetotheproximityofthe
mentalforamen,eventhoughaperforationatadistanceof2.0mmfromthegingivalmarginshouldbewell
awayfromtheneurovascularbundle.Additionally,careshouldbetakentoavoidperforationintothemaxillarysinus.Althoughthiswouldnotresultinaserious
complication,itcouldbeuncomfortabletothepatient

9-TheUseofAnesthesiainEndodontics 223

TableII
Contraindicationsforusingtheintraosseoustechnique

Physicalstructurespreventperforation
Inadequatespacebetweenrootsforperforation
Areasofadvancedperiodontaldiseaseoracuteinfection
Avoidmandibularpremolarregionduetocloseproximityofthementalforamen
Avoidinjectingbetweenmaxillaryandmandibularcentralincisors

andresultininadequateanesthesia.
Otherconsiderationsthatmaydiscourageorprevent
the use of the intraosseous technique are listed in
TableII.

Patientconsiderations
Variousresearchershaveshownthatsolutionscontaining epinephrine injected by the intraosseous route
arerapidlyabsorbedintothesystemiccirculationand
cancauseadecreaseinbloodpressureandincrease
inheartrateinthemajorityofthepatients.Thiseffect
usuallysubsideswithintwotothreeminutes.12,26,27,48
Inanormal,healthypatient,thiscanbefrequentlycircumventedbyinjectingslowlyandreassuringthepatientthattheeffect,shoulditoccur,willbetransient.
For the medically compromised patient, speciically those with cardiac deseases, there are genuine concerns regarding the use or avoidance of vasoconstrictors. Frequently, however, we allow those
concerns to overshadow the actual beneits that the
vasoconstrictoroffers.Thepractitionershouldalways
keepinmindthatifthemedicallycompromisedpatients condition is stabilized through medical treatment, there are no absolute contraindications to the
useofvasoconstrictors,exceptforthosepatientswith
uncontrolled hyperthyroidism with clinical evidence
of thyrotoxicosis and patients with sulite allergies.19
Patientswithuncontrolledhypertension,and/orapresentorpasthistoryofcardiovasculardiseaseareconditionsthatmayrequiremedicalconsultationpriorto
treatment.

Assuming proper injection technique is performed,

vasoconstrictorsareimportantadditionstolocalanestheticsolutions.34
Epinephrine and other vasoconstrictors provide a
widesafetymarginfornormal,healthyadultpatients
and most medically compromised patients who are
stabilized.Paradoxicalasitmayseem,thegreaterthe
medicalriskofapatient,themoreimportanteffectivepainandanxietycontrolbecomes.19Theavoidanceoftheirusewillresultinashorterdurationofthe
anestheticeffect,therebydiminishingthepotentialfor
painlesstreatment.19,34

Otherconsiderations
A small number of patients who receive anesthetic
viaintraosseousroutemaydevelopexudateorswelling at the injection site.9 Although the areas should
healuneventfully,thepossibilityofthisuntowardeffectmustbeconsideredwhenusingtheintraosseous
technique.
Themanufacturerclaimsthatthewoundsitecreated
by the perforator has a surface area approximately
1/700ththesizeofanextractionsocketandgenerally
hasahealthygingivalcovering.59Secondly,theperforatorissuppliedsterile.Aslongastheclinicianisprudentnottoinjectintoareasofactiveperiodontaldiseaseandinfection,thepotentialforinfectionisextremelyrare.
Should swelling or drainage occur, judicious use of
antibiotics, such as penicillin or clindamycin, would
beindicated.

224 Endodontics

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