Periodontal ligament and intraosseous
anesthetic injection techniques
Alternatives to mandibular nerve blocks
Paul A. Moore, DMD, PhD, MPH; Michael A. Cuddy, DMD; Matthew R. Cooke, DDS, MD, MPH;
Chester J. Sokolowski, DDS
he development of safe and effective local
T anesthetic agents has been an important
advancement in dental therapeutics. Their
anesthetic effectiveness, however, some-
times is inadequate, particularly after the adminis-
tration of a mandibular nerve block. The nerves
supplying mandibular teeth and periodontal tissue
are encased in the bone. The thick cortical plate of
the mandible impairs diffusion of anesthetic solu-
tions into the mandible, often limiting the effec-
tiveness of infiltration anesthesia.
Alternative anesthetic techniques that can over-
come this barrier are available. The periodontal
ligament (PDL) anesthetic technique involves
using high injection pressure to force the local
anesthetic solution through the PDL into the can-
cellous medullary bone surrounding a tooth. The
intraosseous (IO) anesthetic technique requires
mechanical perforation of the thick cortical plate
between the roots of the teeth to permit deposition
of the local anesthetic into the medullary bone sur-
rounding the tooth. These techniques permit diffu-
sion of anesthetic around the tooth socket to anes-
thetize all of the nerves supplying the dental pulp.
The anesthesia often is limited to the specific tooth
undergoing treatment.
THE PERIODONTAL LIGAMENT ANESTHETIC
INJECTION
The PDL anesthetic injection technique, also
referred to as the “intraligamentary injection tech-
nique,” can induce local anesthesia in either maxil-
lary or mandibular teeth. Although occasionally it
is used as the primary anesthetic technique (when
a single tooth requires anesthesia for a short dura-
JADA 142(9 suppl)
Copyright © 2011 American Dental Association. All rights reserved.
AB STRACT
Background and Overview. The provision
of mandibular anesthesia traditionally has relied
on nerve block anesthetic techniques such as the
Halsted, the Gow-Gates and the Akinosi-Vazirani
methods. The authors present two alternative
techniques to provide local anesthesia in mandib-
ular teeth: the periodontal ligament (PDL) injec-
tion and the intraosseous (IO) injection. The
authors also present indications for and compli-
cations associated with these techniques.
Conclusions. The PDL injection and the IO
injection are effective anesthetic techniques for
managing nerve block failures and for providing
localized anesthesia in the mandible.
Clinical Implications. Dentists may find
these techniques to be useful alternatives to
nerve block anesthesia.
Key Words. Dental anesthesia; local anes-
thesia; periodontal ligament injection;
intraosseous injection.
JADA 2011;142(9 suppl):13S-18S.
Dr. Moore is a professor of pharmacology and epidemiology, and the chair,
Department of Dental Anesthesiology, School of Dental Medicine, Univer-
sity of Pittsburgh. Address reprint requests to Dr Moore at G87 Salk Hall,
Department of Dental Anesthesiology, School of Dental Medicine, Univer-
sity of Pittsburgh, Pittsburgh, Pa. 15261, e-mail “pam7@pitt.edu”.
Dr. Cuddy is an assistant professor, Department of Dental Anesthesiology,
School of Dental Medicine, University of Pittsburgh.
Dr. Cooke is an assistant professor, Department of Dental Anesthesiology,
School of Dental Medicine, University of Pittsburgh.
Dr. Sokolowski is the chief resident, Dental Anesthesiology Residency,
University of Pittsburgh Medical Center.
http://jada.ada.org September 2011 13S
tion), dentists most often use the PDL technique
when mandibular nerve blocks are unsuccessful.1
Teeth with irreversible pulpitis generally are
considered the most difficult to anesthetize and
often require supplemental anesthesia.2 Investi-
gators surveyed members of the American Asso-
ciation of Endodontists to assess the use of sup-
plemental PDL and IO injections. They found
that symptomatic irreversible pulpitis was the
endodontic diagnosis that most often required
some form of supplemental anesthesia, with the
PDL anesthetic injection technique being the
most frequently administered.3
The PDL anesthetic injection technique was
introduced in the early 20th century and gained
popularity in the 1970s when dedicated high-
pressure dental syringes such as the Peripress
Pen (Panadent, Kent, England) and Ligmaject
(Henke-Sass, Wolf, Tuttlingen, Germany) were
introduced. These syringes could be operated with
one hand and were capable of delivering small
volumes of anesthetic from standard dental car-
tridges at the high hydrostatic pressures required
for the PDL anesthetic injection. Today, there is
an array of mechanical and computer-assisted
equipment engineered specifically for this anes-
thetic injection technique, including the Intra-
Flow Intraosseous Anesthesia Delivery System
(Pro-Dex, Irvine, Calif.), the Midwest Comfort
Control Syringe (Dentsply Professional, York,
Pa.), the STA Single Tooth Anesthesia System
(Milestone Scientific, Livingston, N.J.), The Wand
handpiece (Milestone Scientific) and the Compu-
Dent instrument (Milestone Scientific). Although
the authors of three studies did not report
improved efficacy with the use of computer-
assisted instruments, these tools may provide an
advantage by providing more precise control of
the injection rate and pressure.4-6
The administration procedures are similar
when using a conventional syringe or a syringe
dedicated to PDL anesthetic injection technique.
Malamed7 recommended using short 27- or 30-
gauge dental needles for this technique. With the
tip of the needle approaching the periodontal
sulcus on the mesial or distal aspect of the tooth,
advance it to the base of the periodontal crevice.
With the bevel oriented toward the root surface,
advance the tip of the needle into the PDL
between the root surface and the adjacent alve-
olar bone. Administer a small amount (0.2 milli-
liters) of anesthetic solution slowly. To ensure
that the solution is being forced into the tissue,
you must feel resistance. Although syringes differ
among manufacturers, the technique usually
requires deposition of at least 0.2 mL for each
root of the tooth. Figures 1, 2 and 3 show the ori-
14S JADA 142(9 suppl) http://jada.ada.org September 2011
Copyright © 2011 American Dental Association. All rights reserved.
entation of the syringe and the position of the tip
of the needle into the PDL.
The name of the technique may be misleading.8
Although the solution is deposited into the
coronal segment of the PDL, the anesthetic is not
forced down the PDL to the tooth apex but
instead is redirected into the surrounding cancel-
lous bone through the fenestrations in the dental
socket. Unlike the cortical plate of the mandible,
the dental socket has multiple passageways to
accommodate the blood vessels that supply the
periodontium. Investigators used a dog model to
simulate this clinical technique and assessed the
distribution of the local anesthetic after the PDL
injection was administered.9 By administering a
solution containing suspended carbon particles,
they found that the solution was distributed into
the soft tissue and adjacent hard structures next
to the tooth. The distribution was consistently
more widespread when they administered injec-
tions using moderate to strong pressure. The
investigators’ conclusion was that the PDL anes-
thetic injection technique was a form of the IO
anesthetic injection technique.
The results of the first published clinical
assessment of the PDL anesthetic injection tech-
niques showed that success rates ranged from 60
percent for endodontic therapies to 100 percent
for periodontal therapies and tooth extractions.10
Anesthesia onset was rapid, and anesthesia dura-
tion was 30 to 45 minutes. Adverse reactions
included pain during administration of the injec-
tion, tenderness at the injection site after treat-
ment and a subjective sensation that the tooth
was elevated in the occlusion or “high” after treat-
ment. Investigators in another comparative study
reported similar results.9 They noted slight
increases in heart rate.11
Investigators compared the inferior alveolar
nerve block (IANB) supplemented with the buccal
infiltration anesthetic injection technique with
the IANB supplemented with a PDL anesthetic
injection.12 Anesthetic success in patients with
irreversible pulpitis in the mandibular first molar
for these combinations of treatments was compa-
rable (81 percent versus 83 percent; P > .05).
Investigators have attempted to determine the
most effective local anesthetic agent for the PDL
injection technique.13 They compared injections of
4 percent articaine with 1:100,000 epinephrine
with 2 percent lidocaine with 1:100,000 epineph-
rine administered with the PDL injection and
found no significant differences in pain during
administration of the injection, heart rate
ABBREVIATION KEY. IANB: Inferior alveolar nerve
block. IO: Intraosseous. PDL: Periodontal ligament.
Figure 1. Intraoral photograph showing the
position of the needle for the periodontal liga-
ment anesthetic injection technique.
increase and postinjection pain. Using electric
pulp testing of mandibular molars to assess anes-
thetic efficacy, these investigators compared
1.4 mL of 4 percent articaine with 1:100,000 epi-
nephrine with 1.4 mL of 2 percent lidocaine with
1:100,000 epinephrine administered with the
PDL injection and found that successful pulpal
anesthesia was comparable for the two anes-
thetics (86 percent for the articaine solution and
74 percent for the lidocaine solution; P > .05).14
Because the PDL anesthetic injection tech-
nique requires only a small volume of local anes-
thetic solution, systemic toxicity is reported
rarely. The PDL anesthetic injection technique
provides an advantage over regional nerve blocks
by inducing anesthesia in only one or two teeth.15
In situations in which anesthesia of a short dura-
tion is required, the PDL anesthetic injection
technique might be the preferred treatment. This
technique avoids the deep needle insertion asso-
ciated with mandibular regional blocks and may
be considered a safer alternative technique for
patients with bleeding disorders. For example,
Yamashiro and Furuya16 described a case of a
patient having a large mandibular hemangioma.
They administered a PDL injection to avoid the
possible rupture, vascular trauma and excessive
bleeding potentially occurring with the IANB.
The anesthetic efficacy of the PDL anesthetic
injection technique can be unreliable if the
needle is not positioned precisely.8 Malamed7
recommended not administering injections into
inflamed or infected periodontal sites.
The current American Heart Association rec-
ommendations do not provide specific guidance
regarding antibiotic prophylaxis when adminis-
tering the PDL injection.17 The recommendations
state that antibiotic prophylaxis is not needed
with routine anesthetic injections through nonin-
fected tissue. However, even when it has been
Copyright © 2011 American Dental Association. All rights reserved.
Figure 2. Radiograph showing the needle position Figure 3. Illustration of
for the periodontal ligament anesthetic injection the needle position for
technique. the periodontal
ligament anesthetic
injection technique.
administered through healthy periodontal tissue,
the PDL injection has induced bacteremia.18
Because of the potential for bacteremia to induce
bacterial endocarditis, dentists should consider
antibiotic prophylaxis when administering PDL
injections, particularly when administering an
injection through inflamed periodontal tissue. For
the few patients who have a known risk of devel-
oping bacteremia-induced endocarditis, avoiding
the use of the PDL anesthetic injection technique
is a practical alternative when possible.
A disadvantage of routinely using the PDL
anesthetic injection technique is that some
patients report tenderness at the injection site
for a day or two after treatment.19,20 Among the
commonly used local anesthetic injection tech-
niques, patients described needle placement
during the administration of an IANB as most
painful, followed by the PDL anesthetic injec-
tion technique and the mental nerve block injec-
tion and infiltration anesthetic injection tech-
niques. They reported that the PDL anesthetic
injection technique was the most uncomfortable
during solution deposition.21
The position of the needle and the pressure of
the injection can cause trauma to tissue and sub-
sequent postoperative discomfort. The PDL anes-
thetic injection technique is not recommended for
primary teeth, because there have been cases of
enamel hypoplasia and hypomineralization in
permanent teeth adjacent to the injection site.22
The results of histologic evaluations after the
PDL injection was administered indicated min-
imal damage to the crestal bone, followed by
rapid repair and healing.23 Other investigators
noted disruption of PDL tissue and indications of
active external root resorption with microscopic
evaluations of dog periodontium after they
administered PDL anesthetic injections.24
Patients sometimes report having a sense that
JADA 142(9 suppl) http://jada.ada.org September 2011 15S
Figure 4. Intraoral photograph showing the position of
the needle for the intraosseous anesthetic injection tech-
nique. Image of X-Tip reproduced with permission of
Dentsply Maillefer, Tulsa, Okla.
the anesthetized tooth is protruding after admin-
istration of a PDL anesthetic injection. This sen-
sation can be minimized if the dentist avoids
using excessive injection pressure and volume.7
THE INTRAOSSEOUS ANESTHETIC
INJECTION
Although maxillary infiltration anesthetic injec-
tion techniques may have success rates of 95 per-
cent or higher, the success rates for IANBs gener-
ally are 80 to 85 percent.7,25 Lower success rates
may be due to the greater density of the buccal
alveolar plate (which restricts supraperiosteal
infiltration), limited access to the inferior alve-
olar nerve and a wide variation in neuroanatomy.
With pulpitis, hyperalgesia may be another
reason for anesthetic failure. Inflamed tissues
may alter the nerves’ resting membrane poten-
tials and decrease excitability thresholds,
changes that are not restricted to the inflamed
pulp but affect the entire neuronal pathway,
extending to the central nervous system. There-
fore, routine local anesthetic techniques may
not prevent nerve transmission adequately
because of the lowered excitability thresholds.26
A description of the IO anesthetic injection
technique was first published in 1910.27 The
author described a technique for delivering local
anesthetic to the root tip via a small drilled hole.
The technique lacked popularity because dentists
were reluctant to drill into cortical bone and had
difficulties inserting a needle precisely into the
tight fit of the drilled hole. Early techniques
included instrumentation with a half-round bur
or a motorized endodontic reamer and a standard
27-gauge short needle. The volume of anesthetic
administered ranged from 0.5 to 1.5 mL. Owing
to the lack of intimate fit between the needle and
the hole, the effective volume often was less than
16S JADA 142(9 suppl) http://jada.ada.org September 2011
Copyright © 2011 American Dental Association. All rights reserved.
Figure 5. Radiograph showing Figure 6. Illustration of the
the perforation site for the needle position for the intra-
intraosseous anesthetic injection osseous anesthetic injection tech-
technique. nique. Image of X-Tip reproduced
with permission of Dentsply
Maillefer, Tulsa, Okla.
the total volume administered because of leakage
at the injection site.27
Instruments. As the IO technique evolved,
instruments were designed to control deposition
of the solution, including the Stabident system
(Fairfax Dental, Miami) and the X-Tip dental
anesthesia system (Dentsply Maillefer, Tulsa,
Okla.). The technique requires perforating the
cortical bone by creating a small hole between
the roots of the teeth with a specialized rotary
instrument. The dentist makes the perforation
approximately 5 millimeters apical to the buccal
papilla. Applying constant pressure when the
perforator is against the cortical plate can lead
to a buildup of heat. Malamed7 recommended
using a light pecking motion with the handpiece
as the perforator goes through the cortical plate.
The X-Tip system has a unique design that
leaves a guide in place after perforating the cor-
tical bone to make it easier to insert the needle
through the perforation. The administration of
an injection of one-quarter to one-half of a car-
tridge of local anesthetic by means of a small
needle guided into the trabecular bone can
induce anesthesia (Figures 4, 5 and 6).
Initially, dentists used the IO anesthetic tech-
nique as a supplementary technique when the
IANB failed, especially in cases of irreversible
pulpitis.28-34 With the advent of products such as
Stabident and the X-Tip, the technique has
gained in popularity as a primary technique for
anesthetizing a single mandibular tooth. Al-
though dentists use the IO technique most often
to provide anesthesia in a single tooth, they may
use it to anesthetize multiple teeth in the same
quadrant, depending on the injection site and
volume of anesthetic injected.1
When an IANB was supplemented with an IO
injection, investigators reported a substantial
increase in the overall anesthesia success rate for
first molars and second premolars.28 For teeth
with irreversible pulpitis, the administration of a
supplemental mandibular IO injection increased
total pulpal anesthesia success.29,31-34 The onset of
anesthesia after the IO injection was adminis-
tered was almost immediate. Study results indi-
cate that pulpal anesthesia has a duration of as
long as 60 minutes when used with a vasocon-
strictor and approximately 15 to 30 minutes
when used without a vasoconstrictor.34,35
Contraindications. Contraindications to
the use of the IO anesthetic injection technique
include gross periodontal disease or acute peri-
apical infection. Formation of fistula has been
reported at perforation sites.7 This technique
should be used cautiously in cases in which the
roots of the teeth are so close together that they
preclude clear access to the interdental trabec-
ular bone. A relative contraindication is when
there is difficulty perforating the cortical plate
where it is thick, such as areas distal to the
second molar, increasing the chance of perfo-
rator fracture.7 Some areas of the mandible also
may have constricted cancellous bone, which
may impede anesthetic distribution.33
Adverse effects and complications. There
are some possible adverse effects and complica-
tions of using the IO technique.36 Heart palpita-
tions frequently occur when a vasopressor-con-
taining anesthetic is used. To minimize the risk,
a slow injection using a local anesthetic without
a vasopressor, such as 3 percent mepivacaine, is
recommended. Only one-eighth to one-quarter of
a dental cartridge should be administered at
one time until adequate anesthesia is achieved.
Because the cancellous bone in the mandible is
vascular, keep the volume of local anesthetic to
the recommended minimum to avoid possible
rapid systemic uptake and overdose.
The use of vasoconstrictors is dictated by
treatment needs and patients’ health histories.
Patients with moderate to severe cardiovascular
disease or who are taking tricyclic antidepres-
sants or nonselective β-adrenergic blocking
agents are poor candidates for use of the IO anes-
thetic injection technique when solutions con-
taining epinephrine or levonordefrin are used.34
Investigators have reported a transient
increase in heart rate after administration of
vasopressor-containing anesthetic solutions by
means of IO injections. Coggins and colleagues35
found that 60 percent of participants reported
perceiving an increase in heart rate as deter-
mined by subjective questioning after administra-
tion of an IO injection of 1.8 mL of 2 percent lido-
caine with epinephrine 1:100,000. Replogle and
JADA 142(9 suppl)
Copyright © 2011 American Dental Association. All rights reserved.
colleagues34 reported that 67 percent of partici-
pants had an objective increase in heart rate as
determined by means of electrocardiography
when 2 percent lidocaine with epinephrine
1:100,000 was administered by means of IO injec-
tion.34 The mean increase in heart rate was 28
beats per minute. Investigators in other studies
found similar increases in heart rate when local
anesthetics with vasconstrictors were adminis-
tered.28,39 Replogle and colleagues34 and Chamber-
lain and colleagues39 did not observe any clinically
significant changes in blood pressure after admin-
istration of IO injections of 2 percent lidocaine
with 1:100,000 epinephrine.
In general, the results from all of these
studies showed that the heart rate returned to
baseline within four minutes in most patients.
To reduce patient anxiety, inform patients that
they may experience a transient increase in
heart rate and that any symptoms of palpita-
tions are short-lived and will dissipate quickly.
The administration of IO injections with 3 per-
cent mepivacaine plain has not produced a clini-
cally significant increase in heart rate,34 so
there is no need to inform patients about an
increase in heart rate with the use of mepiva-
caine 3 percent without a vasoconstrictor.
Pain during the perforation, as well as after
the procedure, is another complication.5 Reisman
and colleagues31 noted that 27 percent of patients
reported having moderate pain and 6 percent
reported having severe pain during administra-
tion of the injection. There was a 2 to 15 percent
incidence of postoperative pain at the injection
site that dissipated within a few days and a 4 to
5 percent incidence of swelling, bruising or puru-
lence that healed within two weeks. Four to 13
percent of patients reported that their teeth felt
“high” for a few days after the IO injection was
administered.
Although rare, separation of the perforator or
needle can occur. If this happens, the perforator
or needle cannula usually gets lodged in the bone.
A hemostat can be used to remove the fragment
from the bone.35,37 Perforation of the lingual plate
of the bone or injury to the roots of the teeth can
occur. The IO anesthetic injection technique is not
recommended for use in areas of mixed dentition
because of insufficient cancellous bone and the
possibility of damaging developing tooth buds.38
CONCLUSIONS
PDL and IO anesthetic injection techniques can
be used in dentistry to induce local anesthesia.
They provide alternative approaches to estab-
lishing effective anesthesia for mandibular
dental procedures and are particularly useful
http://jada.ada.org September 2011 17S
when mandibular nerve block anesthesia has
failed. Adverse reactions such as stimulation of
the cardiovascular system, injection pressure
discomfort and postoperative tenderness have
been reported. Advanced anesthetic methods
permitting controlled administration may mini-
mize adverse reactions associated with these
alternative techniques. ■
Disclosures. Dr. Moore is a consultant to the Pharmacovigilance
Division of Dentsply International, York, Pa. Drs. Cuddy, Cooke and
Sokolowski did not report any disclosures.
The authors thank Christine T. Bettinger for the illustrations
created for Figures 3 and 6. They also thank Darcie Burns for her
assistance in the editing this manuscript.
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