This month’s editorial deals with one of the greatest mysteries of dentistry and life itself, the inferior alveolar nerve block, affectionately known as the “block”.
Back in the “good old days” of dental school I was taught to administer this injection by feeling/guessing where the ramus of the mandible was, then palpating the bone until I miraculously detected some obscure notch (hamular, belt, not really sure at this point since I can barely remember what happened yesterday) and injecting from the ipsilateral (or was it contralateral and why are we the only people on Earth who use the term “ipsi”?) side when the 27 gauge harpoon size needle struck gold.
After waiting for lunch to be served and devoured, the patient typically was drooling from the injection side, couldn’t feel their lip or tongue and was ready for the long awaited buccal pit on number 30 to be restored. Unfortunately, despite experiencing complete numbness from the orbit down to the esophagus, the patient inevitably screamed their brains out once the carbide bur penetrated enamel.
After several episodes like this, culminating with an incident during which a wide eyed patient writhing in pain from an unsuccessful attempt to extract an abscessed number 30 bolted from my chair, I thought to myself there had to be a better way. Luckily there was a myriad of “alternative techniques” to try, such as the Gow-Gates, Akinosi, Dow Jones, Samurai, Bear Stearns and of course the Hail Mary.
However, after falling into a coma trying to read about the Gow-Gates technique, I came to the conclusion it was time to toss the block and start doing mandibular injections differently. Luckily my Dad, also a dentist, had a few ligaject syringes which he wasn’t using, and after a few tries, a lightning bolt struck as I came to the conclusion that I had struck mandibular anesthesia oil.
The icing on the cake came when Septocaine was approved for use in the USA. The technique is as follows: say, for example, I’m doing an extraction on a lower molar. First I will infiltrate on both the buccal and lingual of the tooth, then follow with the ligaject around the PDL of the tooth – typically on the mesial-buccal, mesial-lingual, distal-buccal and distal-lingual areas.
For it to be effective, the gingiva must blanch and the injector must feel pressure. The only negative of this technique is it can create pain. The anesthesia must be deposited slowly. However, anesthesia is instant, is profound and has the added benefit of achieving hemostasis.
For fillings on lower premolars I’ll skip the PDL injection and just infiltrate. For all root canals and extractions I use the ligaject as well as for some fillings on lower molars, depending on if the initial infiltration is successful. I always use Septocaine, even on those loons that insist they’re “allergic to epi”.
The only drawback to doing mandibular injections this way is possible tissue necrosis or post-op pain or infection. However, this is preferable to a block that takes 5 to 10 minutes to “work” (if it does), requires shoving a large needle down a fearful patient’s throat, may cause paresthesia and, of course, a nice certified letter from your local malpractice attorney. For me, there is no choice. Ban the block!