One of the most frustrating aspects of dentistry for even the most experienced of practitioners is

difficulty attaining local anesthesia with the mandibular teeth. It is commonly known that,
according to the study you read, only 80 - 85% of mandibular blocks are successful.

When they are not it:

1. Creates anxiety in the patient

2. Frustrates the dentist
3. Puts undue pressure on the daily schedule of the patient and the dentist due to "having to
wait on it".
4. Requires the dentist to try to achieve the required level of comfort by the addition of
much more medication which is not helpful to the patient. I have actually had patients
come to me with stories of the dentist dismissing the patient to reappoint to another day
due to the patient not getting "numb".
5. Gives additional risks of increased heart rate due to inadvertent arterial infection or
paresthesia from mandibular nerve trauma.
6. Increases the risk of a hematoma.

Advantages of the "spot on technique" are:

1. Instant anesthesia, therefore you can begin treatment immediately.

2. Less medication is administered to the patient.
3. It is more comfortable than the mandibular block. Many times a patient will ask "Did
you give me a shot?"
4. A more profound anesthesia. Many times patients will exclaim that this is the first time
they have been truly numb on that side. I commonly hear that a previous dentist had told
them that "it is just them, and that they are hard to numb."
5. Fewer traumas than intraosseus techniques. I have seen tissue sloughing with this route.

Armamentarium:

1. An intraligamentary syringe. My choice is the style that is index finger activated vs. the
pistol grip. It tends to be easier to control and seems to be easier to get the "clicks"
indicating doses administered.
2. A 30 gauge extra short needle
3. 4% Articaine with 1:100,000 epinephrine
4. 4% Prilocaine HCl plain
5. A standard syringe with a 30 gauge short needle
6. Possibly most important is a compounded triple topical anesthetic mix of benzocaine,
lidocaine and tetracaine.
7. A carpule warmer

The Technique is as follows: Give five minutes to allow the topical to do its job. Apply to the
vestibule as well as the entire buccal gingival margin of the tooth. With the Standard syringe,
slowly inject 4% prilocaine plain in the vestibule. This should be practically imperceptible to the
patient. Next slide the 30 gauge needle under the free gingival margin. The idea is literally to
drip the anesthetic into the area with a slight pressure. Increase this action to moderate pressure
going from line angle to line angle of the buccal of the tooth. Be sure to keep aspiration active
the entire time as leakage will occur and to avoid the bitter taste. Copious water rinses help here
as well.

Next using the intraligamentary syringe with 4% Articaine with 1:100,000 epinephrine slowly
engage the bifurcation on the buccal. The feeling you should have is moderate pressure or
squeezing that is required to force the solution into the space of the periodontal ligament. You
should get a click as each dose is administered. Normally 4 to 5 clicks per site are sufficient. It
is very important to get the feel as the technique requires you to get into this specific area.
Anatomical differences in the height of the furcation relative to the free gingival margin can
require you to adjust the angle to approximately 45 degrees. Picture the needle as sliding into the
area. I prefer to repeat the process at the line angles in a similar fashion. Again, if done
properly, with lighter pressure to start increasing pressure in the last couple of clicks the patient
should have little difficulty noticing any of the traditional feelings of a "shot". On rare occasion,
the tooth may require the same process on the lingual repeating the steps outlined above.

It is a wonderful feeling to be able to achieve patient comfort without their lips and tongue
feeling swollen for 3 to 4 hours. We all dislike hearing our patients say "I just hate that numb
feeling". The majority of the time our patients are referring to the after effects of the traditional
mandibular block - and it may have been only 90% effective! It is a difficult process to get a
referral from one of our patients who had to endure pain of any kind during dental treatment.

In summary the Dr. Richard Lepard Spot-On Local Anesthesia Technique gives you profound
anesthesia with less medication, freedom from anatomical areas of complication, i.e. hematomas
or parathesis in the mandibular nerve complex. It further removes the variance of the angle of the
mandibular as influence of "missing the block." It is a way to WOW your patients and de-stress
your day with another successful local anesthesia experience.

You can read more of Dr. Lepard's articles through his website TravisWalkDental.com or his
blog DallasDentistBlog.com

Dr. Richard L. Lepard has been practicing dentistry for 30 plus years here in Texas. His dental
practice, Travis Walk Dental, is among the leading cosmetic dental offices in Dallas, TX. Dr.
Lepard is an expert in cosmetic and sedation dentistry with thousands of hours in continuing
education from leading dental societies.