For the first half of my dental career, inferior alveolar nerve blocks were unpredictable. Often I had to give multiple injections with different anesthetics hoping to get adequate anesthesia to proceed with dental care. There were times when a patient would be rescheduled because I had failed miserably with the blocks. The only thing that got numb was my ego.

I do not have a problem with IAN blocks anymore, because I do not use them. I have tried Ligmaject and Stabident systems. Ligmaject was mildly successful. It would probably be more successful with the technique I use now. Stabident was very successful, but I had three incidents of bone necrosis. I believe in baseball: three strikes and you’re out.

At an Academy of General Dentistry convention in Hawaii sometime around Y2K, I listened to Dr. Stanley Malamed. He introduced me to the benefits of Septocaine.  He also discussed several injection techniques. A light bulb went off in my head and my journey to help my failing IAB ego started.

The following is what I do today for anesthesia. There can be many variations, so try to make it your own.

How to perform dental anesthesia without an IAN block

For the maxillary teeth, infiltrations work well. For bicuspids and incisors in the mandible, mental blocks are easy and effective. Mandibular molars get numb predictably now. 

I first place a topical anesthetic in the buccal fold of the tooth/teeth I plan to work on. My first injection is with a 30 gauge short syringe (the only syringe tip I use) with a pH balanced anesthetic (4 percent Citanest plain) that pierces the tissue and is injected slowly. This helps to prevent the sting or burn associated with anesthetics.   

I follow that with half a carpule of Septocaine, which now is painless. This allows the soft tissue to get numb.

I look at my syringe tip and orient the bevel towards the tooth. Look for the dot manufacturers place on the hub.

anesthesia with septocaine

The tip is placed at the buccal furcation of the tooth. Slide it subgingival parallel to the root surface until it contacts the bone/periodontal ligament area.

administer dental anesthesia without ian block

Push the syringe apically with mild pressure to wedge it into the PDL space.  Slowly inject half a rubber stopper amount into this area. You want to feel a fairly good amount of back pressure. 

If the solution goes in freely, you probably are not getting into the PDL, and are not likely to get good results. Repeat this injection at the lingual furcation.

The anesthesia comes on quickly - I put down my syringe and pick up my drill to start. Sometimes, but not often, a patient needs a booster shot if they feel a bit as we work. I will re-inject the same sites, but probably will now go to six points around the tooth, as if I was perio probing using the same technique described. It takes less than a minute, then back to spinning my bur.

Additional comments and variations:

When I have had to do minimal work on a single molar, I have jumped to the step of injecting the buccal and lingual furcation with Septocaine. I warn them they may feel a pinch for a moment, but most do not. Patients get the work done comfortably and walk out of the office without feeling numb (or feeling minimally so). 

Does this injection technique create anesthesia by just reaching the furcation, or does it go all the way to the apex?

I have used this injection on other teeth with success when a patient expresses a concern about the numb feeling (using the six points mentioned above). However, infiltration with a Carbocaine-Septocaine cocktail is my first choice.

If I could find where I put my Ligmaject, I would probably try this technique with it.  I have had no problem creating enough pressure to get profound anesthesia using just a regular syringe.

Let your patients know that the anesthetic may drip out as you inject, and it tastes terrible.

When I have shared what I do with others, some seem to be non-believers … until they try it.

I hope this helps make your challenging anesthetic situations easier. It has for me. Anyone want a few boxes of 27 gauge long needles?

Carl E Steinberg, DDS, MAGD, LLSR, ​









Commenter's Profile Image Julie C.
April 25th, 2018
Do you use this technique when you're doing a crown prep as well? I am wondering patients are still comfortable when you're packing cords. Thank you for sharing.
Commenter's Profile Image Carl S.
April 25th, 2018
Hi Julie I use this technique for any dentistry I do on mandibular molars. Patients have been comfortable with all procedures. Soft tissue is numb from the long buccal anesthetics and the PDL's. Like anything else that you do, you need to get some successes to build confidence. Try it, you'll like it! Carl
Commenter's Profile Image Chip W.
April 25th, 2018
Can you clarify the amount you are injecting when you say "Slowly inject half a rubber stopper amount into this area"? That doesnt sound like much anesthetic. I use the Septodont PDL syringe quite a bit with an extra short needle. It is way less intimidated to the patient than the ligamaject. It produces good pressure and seems to be easier to slip into the PDL space with the extra short needle. I normally give two full clicks at each point, which seems like more than you are giving.
Commenter's Profile Image Stephen B.
April 26th, 2018
I have tried this technique a few times and discussed it with colleagues that have also tried it. We've all had the same result: The local infiltration does not get the PDL numb and the PDL injection pressure is extremely painful to the patient. To top it off, the anesthesia doesn't last more than a short period. Even if you had success with the buccal PDL shot not being extremely painful, the lingual booster area wouldn't be numb from the local infiltration of citanest so that one would still be extremely painful as well.
Commenter's Profile Image Carl S.
April 26th, 2018
Hi Chip I generally do not have to inject very much. I do use a standard syringe so I watch how far the rubber stopper moves. So I suppose a half a stopper or so is 1/10-1/15th of a carpule. When I inject the long buccal area with septocaine I generally leave 1/3 for the PDL. Sometimes, but not often, I have put a new carpule in so my hand/fingers expand and I can apply more pressure. I hope this clarifies it a bit. Carl
Commenter's Profile Image Carl S.
April 26th, 2018
Hi Stephen I an sorry to hear the results you have had. We know that one technique doesn't work for everyone. I can share with you that this is what I have done for quite some time with a high level of success. The injections last enough time for me to do any procedure... sometimes a booster is needed, but not often. I believe the most :painful" part of this technique is when this anesthetic drips out. Sometimes people can feel the lingual furcation injection but it has not been of any concern. I prepare them of it and the taste but the response usually is I barely felt it...yuk...regarding the taste. Usually when I get an opportunity to lecture I start off by saying that you should not believe a word I say unless you are able to take it and make it your own. This works for me but no technique works for everyone. When I have dental guests in our office, this technique is something that usually gets some comments. All the best Carl
Commenter's Profile Image Sharell S.
April 26th, 2018
Hello Dr Stephen My name is Sharell Smith, I am one of Dr Steinberg assistants. I have been assisting chair side with Dr Steinberg for approximately 7months and throughout this time I have seen the PDL injection technique use for every dental procedure. In my opinion the success rate is 95%. My perception is that most of the patients feel very minimal burning with the injections if any , just the nasty taste of the anesthetic. Patients seems to be comfortable during the procedures, if there is any extra anesthetic needed it's a small amount. Patients leave happy because they are not always so numb when they walk out of the office. Wish you the best with finding an technique that works for you Sharell
Commenter's Profile Image Steven H.
April 28th, 2018
Carl thanks for informative post. I will start to use and see how it goes. I did read ALL procedures but just for clarity endo and extractions also?
Commenter's Profile Image Carl S.
April 28th, 2018
Hi Steven H I do use it for endo and while I do not do many exts today, I have used this technique with success and predictability. Best of luck Car
Commenter's Profile Image Jill K.
April 29th, 2018
Thanks for sharing. I use a similar PDL injection technique using the Ligmaject and love it. Very quick and effective. Thanks for the tips!
Commenter's Profile Image Sylvie R.
May 8th, 2018
Thanks for the great info. My patients love not having the frozen tongue. I always thought the IAN block was so invasive even after 22 years at this. I also get a gold star from my patients when I use Oraverse to turn off the local.
Commenter's Profile Image Jim F.
May 10th, 2018
Have you tried this with marcaine to see if the effect will last longer?
Commenter's Profile Image Carl S.
May 10th, 2018
Hi Jim Never used Marcaine for this. Let me know how it works. Carl
Commenter's Profile Image Devin M.
July 31st, 2018
Hi Carl, Can you give the injection with adequate pressure with a conventional syringe or just the Ligmaject? Thanks! Devin