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JOURNAL OF ENDODONTICS

Printed in U.S.A.

Copyright 9 1984 by the American Association of Endodontists

VOL. 10, NO. 4, APRIL 1984

CLINICAL ARTICLES A Comparative Study of the Gow-Gates Technique and a Standard Technique for Mandibular Anesthesia
Thomas A. Montagnese, DDS,MS, AI Reader, DDS,MS, and Rudy Melfi, DDS,PhD

A comparative study was made of the Gow-Gates technique and the standard inferior alveolar nerve block. Forty subjects received both injections and various tests were performed 10 min after injection. The results demonstrated no significant differences between the two injection techniques, except in response to the question concerning subjective tongue numbness. Both techniques achieved a high rate of subjective numbness in the subjects' perception of overall numbness and lip numbness. Objective testing showed that only 38% of the subjects receiving the standard injection and 35% of the subjects receiving the Gow-Gates technique gave no response to the electric pulp tester at the maximum output (80/80).

comparative study of the conventional technique versus the Gow-Gates injection, found no difference in analgesic effect between the two methods. The purpose of this study was to compare the effectiveness of the Gow-Gates technique with the standard inferior alveolar nerve block technique. MATERIALS AND METHODS Forty subjects, 25 males and 15 females ranging in age from 14 to 68 yr, were used in this study. All subjects or their legal guardians signed a consent form explaining the experimental procedures and risks. Based on both a clinical written medical history and oral questioning, the subjects were judged to be in good health, were currently taking no medications, and had never had an allergic or toxic reaction to a local anesthetic agent. Prior to either injection, three sets of tests were performed by trained auxiliaries and recorded. A sharp dental explorer was firmly pressed into the attached gingiva at the facial and lingual aspects of the permanent cuspid and the buccal aspect of the first permanent molar. The subject's response was recorded for each test site. These procedures tested the response of the inferior alveolar, lingual, and long buccal nerves, respectively. An ice carpule was applied for a maximum of 15 s to the facial aspect of the mandibular permanent lateral incisor which was free of caries, restorations, and exhibited no clinical signs or symptoms of pathosis. The subject's response was recorded as positive or negative. This procedure tested the response of the incisive nerve. An Analytic Technology digital electric pulp tester (Redmond, WA) was used on the same lateral incisor tested with ice. The maximum output reading was 80 and all readings were expressed as a fraction of 80. The tooth was dried with a 5-s application of compressed air. The electrode was coated with a small amount of toothpaste and placed in contact with the anatomical crown of the tooth near its center. When
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Pain relief and the prevention of pain has been one of the main objectives in dentistry. A commonly used method to prevent pain is to inject a local anesthetic solution adjacent to a nerve. However, in some instances, the patient complains of pain despite an apparently successful mandibular block. This is particularly true in endodontic therapy when extirpating an acutely inflamed pulp of a mandibular molar. Gow-Gates (1), in 1973, introduced a technique for a mandibular nerve block using extraoral landmarks. The injection used a more lateral approach at a higher level than the conventional inferior alveolar nerve block. The injection would supposedly anesthetize the nerve closer to the site of exit from the cranium and would block any nerves which branched at a higher level after leaving the foramen ovale, resulting in profound mandibular anesthesia. The branched nerves would not be anesthetized by the more inferior approach of the conventional technique. Success rates of 92 to 100% have been reported using this technique (2-6). In these same studies, the standard technique achieved success rates of 65 to 86%. However, Agren and Danielsson (7), in a

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the subject indicated feeling a sensation within the tooth, the electrode was withdrawn and the number recorded. This procedure also tested the response of the incisive nerve. Forty subjects were administered local anesthetic for unilateral mandibular anesthesia at two separate appointments by the senior author. At the initial appointment, one-half of the subjects received local anesthetic via a standard technique for mandibular anesthesia and the other half of the subjects received local anesthetic via the Gow-Gates mandibular block technique (1). Seven to 10 days later, the 20 subjects who received the standard injection initially were administered the Gow-Gates block and the other 20 subjects who initially received the Gow-Gates injection were given the standard block. The subjects, at both appointments, were unaware of which injection they were receiving. A total of 18 standard injections were given for right mandibular anesthesia and 22 injections for left mandibular anesthesia. A total of 18 Gow-Gates injections were given for right mandibular anesthesia and 22 injections for left mandibular anesthesia. The same injection side, right or left, was used for each subject at both appointments. The anesthetic solution used for all injections was 1.8 ml of a 2% Xylocaine (lidocaine) solution with 1:100,000 epinephrine (Astra, Worchester, MA). The solution was injected through a 25-gauge, long disposable needle (Sherwood Med., Inc., Deland, FL) mounted on a conventional aspirating syringe (Astra). Each injection site was dried with a 2 x 2 gauze wipe and no topical anesthetic agent was used prior to injection. The standard injection technique used was the one described by Monheim (8) and Jorgensen and Hayden (9). The patient, placed in a supine position, was asked to open his mouth as wide as possible and the operator palpated the anterior border of the mandibular ramus with the thumb or forefinger, of the free hand, until it rested in the depression of the coronoid notch. The posterior border of the mandibular ramus was then palpated with the opposing finger or thumb to aid in gauging the width of the ramus. The imaginary line established from the coronoid notch to the position of the thumb or finger at the posterior border of the ramus aided in locating the position of the mandibular foramen vertically in relation to the ramus. The syringe was then placed over the contralateral mandibular premolars and the needle was advanced, penetrating the mucosa close to the internal oblique line at a position estimated by bisecting the thumb or fingernail. This puncture point was lateral to the raphe and medial to the deep tendon of the temporalis. The needle was then advanced to the floor of the mandibular sulcus, and the solution deposited, after aspiration, over a time interval of 45 s to 1 min. Five-tenths of a milliliter was reserved to block the lingual nerve as the needle was withdrawn. The Gow-Gates injection technique used was de-

scribed by Gow-Gates in 1973 (1). The senior author used this clinical technique exclusively for a period of 3 wk before beginning the experiment. The subject, placed in a supine position, was instructed to open the mouth as widely as possible. The anterior border of the ramus was palpated with the forefinger. The puncture point was lateral to the pterygotemporal depression and medial to the tendon of the temporal muscle. The needle was then aligned with the plane that extended from the lower border of the intertragic notch through the corner of the mouth. The needle was then paralleled with the angulation of the ear to the face and aimed toward the target area on the tragus of the ear. After initial penetration, the needle was advanced until the bone was palpated at the base of the neck of the condyle or a maximum needle depth of 25 mm was reached without palpating bone. If bone was palpated, the needle was withdrawn 1 mm prior to injection. Aspiration was performed and the solution deposited over a time interval of 45 s to 1 min. The patient was instructed to keep the mouth open for 20 s after the injection. Immediately following the injection, an automatic timer was started and the subject was asked if the injection hurt. The subject's response and the presence or absence of blood in the carpule were noted. A separate sheet recorded the code number for each subject and which injection the subject received at each appointment. At 10 min after injection, a trained auxiliary questioned and tested the subjects without knowledge of which technique was utilized. Another trained auxiliary recorded the subject's responses on the flow sheet. The following questions, requiring a "yes" or "no" response, were asked: "Do you feel numb"?; "Does your lip feel numb"?; "Does your tongue feel numb"?; "Does your cheek feel numb"?. The sharp explorer tests on the facial and lingual aspects of the permanent cuspid and on the buccal aspect of the first permanent molar were repeated and recorded. The ice test and electric pulp test (EPT) on the mandibular lateral incisor were also performed and recorded. The data were collected and analyzed using the x 2 test. RESULTS In response to the question, "Did the injection hurt"?, 40% (16 of 40) reported that the standard injection was painful. Fifty percent (20 of 40) of the subjects reported that the Gow-Gates injection was painful. The difference was not statistically significant. Blood was aspirated in 5% (2 of 40) of the subjects during the standard injection and 15% (6 of 40) of the time in the Gow-Gates technique (Table 1). The difference was found not to be significant. The responses to the four questions concerning

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Montagnese et al. TABLE 1. Summary of results: incidence and percentage at 10 min after injection Questions Positive Blood Aspiration General Positive Numbness In B. Cus.* Lip 39 98 39 98 ns Tongue 40 100 34 85 s Cheek 21 53 24 60 ns 33 83 31 78 ns 34 85 29 73 ns 9 23 8 20 ns 39 98 39 98 ns L. Cus. B. Mol. Explorer Test Negative

Journal of Endodontics

Ice EPT Test Negative Negative

Standard Standard (%) Gow-Gates Gow-Gates (%) Significance

2 5 6 15 ns'i"

21 64 21 62 ns

15 38 14 35 ns

* B. Cus., buccalgingivaof cuspid; L. Cus., lingualgingivaof the cuspid; B. Mol., buccalgingivaof the first molar. 1 ns, not significant;s, significant.

numbness at 10 min after injection are summarized in Table 1. With the standard injection, 98% (39 of 40) felt numb, 98% (39 of 40) felt that their lip was numb, 100% (40 of 40) felt numb in their tongue, and 53% (21 of 40) felt cheek numbness. With the Gow-Gates injection, 98% (39 of 40) felt numb, 98% (39 of 40) felt that their lip was numb, 85% (34 of 40) felt numb in their tongue, and 60% (24 of 40) felt cheek numbness. The differences were only significant concerning numbness of the tongue (p < 0.05). The responses to the sharp explorer tests, at 10 min after injection, are presented in Table 1. All subjects reported a positive response to the three explorer tests prior to receiving the anesthetic injections. With the standard injections, 83% (33 of 40) gave no response on the labial gingiva of the cuspid, 85% (34 of 40) gave no response on the lingual gingiva of the cuspid, and 23% (9 of 40) gave no response on the buccal gingiva of the first molar. With the Gow-Gates technique, 78% (31 of 40) gave no response on the labial gingiva of the cuspid, 73% (29 of 40) gave no response on the lingual gingiva of the cuspid, and 20% (8 of 40) gave no response on the buccal gingiva of the first molar. These differences were not statistically significant. The results of the ice test, at 10 min after injection, are presented in Table 1. There was no response to the ice test prior to injections by seven subjects in the standard technique and by six subjects in the GowGates technique. Four of the same subjects did not respond to ice in either injection technique which accounted for 8 of the 13 no responses. These 13 initial no responses were not used in the data analysis for the ice test. In the standard injection technique, 64% (21 of 33) did not respond to ice. With the Gow-Gates technique, 62% (21 of 34) did not respond. The difference was not significant. The results of the EPT's at 10 min after injection, are presented in Table 1. All subjects responded to the EPT at a level below the maximum output before injections were given (Fig. 1). With the standard injection, 38% (15 of 40) gave no response to the EPT at maximum output (80/80). The mean EPT value was 62 (Fig. 1). With the Gow-Gates injection, 35% (14 of 40) gave no response at 80/80. The mean EPT value was 58

Mean electric pulp test values 0 10 20 30 40 50 60

I
Initial

I
I ~

I
Standard injection

After ten minutes FIG 1. Comparative mean EPT values.

(Fig. 1). The differences were found not to be statistically significant.

DISCUSSION

There was a high incidence, 40% for the standard injection and 50% for the Gow-Gates technique, of reported discomfort associated with the injections. Although the question, Did the injection hurt?, required a subjective response and the reply a perceived feeling, it indicated that both injections were painful approximately one-half of the time. However, no distinction was made between the pain of initial needle penetration and the pain of depositing the anesthetic solution. Anxiety may have accounted for a portion of the positive responses. Kleinknect et al. (10) found that the majority of their subjects reported at least moderate anxiety concerning intraoral injections. Kleinknect and Bernstein (11) also indicated that there was a positive relationship between anxiety and pain during dental treatment. Another probable explanation for the rather high incidence of pain was that no topical anesthetic was used. Although the absolute value of topical anesthetic in numbing the mucosa for a mandibular injection may be doubtful, the psychological aspects may warrant its use. The original article on the Gow-Gates technique (1) did not mention the use of topical anesthesia, so we did not include it in our methods. Both techniques utilized injection of the anesthetic solution after the target area was reached. This may have accounted for a higher incidence of pain since the tissue was not anesthetized as the needle was advanced. The rate of injection in both techniques, 45 s to 1 min, may

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have been too rapid and produced a painful response. Since the ideal rate of injection of local anesthetic is 1 ml/min (12), a slower injection rate may not only reduce pain but decrease the intensity of a local anesthetic overdose reaction if an accidental intravascular injection was made. Both injection techniques achieved a high percentage (98%) of perceived overall numbness and lip numbness. However, the percentage decreased when the sharp explorer test was used; 83% gave no response to the labial gingiva of the cuspid in the standard technique and 78% gave no response in the Gow-Gates injection. The only significant difference (p < 0.05) found in this study was in response to the question of feeling numbness in the tongue. One-hundred percent felt tongue numbness in the standard injection and 85% in the Gow-Gates technique. However, the sharp explorer tests revealed no statistical difference between the two techniques when the lingual gingiva of the cuspid was tested, although both percentages were lower than the question of feeling tongue numbness (Table 1). These results indicated that subjective questions were not as reliable as objective tests in judging whether patients had anesthesia. The 5% rate of positive blood aspiration for the standard injection was lower than the value of 12% reported by Bartlett (13). The 15% aspiration rate for the Gow-Gates technique was higher than the reported values of 1.6% by Gow-Gates and Watson (14) and the 1.9% rate reported by Malamed (4). However, this value was about the same as reported by Robertson (17%) (3). The low rate of buccal anesthesia (cheek numbness and the sharp explorer test on the buccal gingiva of the first molar) indicated that the Gow-Gates technique was no more effective than the standard injection in anesthetizing the buccal nerve. Since no separate injection was given for buccal nerve anesthesia in the standard technique, numbness of the buccal gingiva of the first molar would not be expected. However, 23% of the subjects gave no response to this test. It is probable that patients expected to be numb in either injection technique and therefore the placebo effect may have accounted for the rate of patient nonresponse. Previous studies by Robertson (3) and Malamed (4) achieved a 62 and 68% success rate, respectively, for buccal nerve anesthesia with the Gow-Gates injection. Levy (5) reported that 6 of 26 patients required supplemental injections for the long buccal nerve when the GowGates technique was used. ~,gren and Danielsson (7), in a comparative study of the Fischer technique (conventional) versus the Gow-Gates injection, found that complete analgesia of the buccal mucosa occurred in 7 of 12 cases with the Gow-Gates technique. Five of 12 cases had complete analgesia of the buccal mucosa in the conventional technique even though no separate buccal injection was performed. The long buccal nerve,

in anatomical descriptions (15, 16), passes through the infratemporal fossa in a downward and forward direction, courses laterally between the two heads of the lateral pterygoid muscle, and is then associated with the medial and anterior aspect of the tendon of the temporalis muscle. It emerges from beneath the anterior border of the masseter muscle and continues in an anterolateral direction. At about the level of the occlusal plane of the mandibular second and third molars, it crosses the anterior border of the mandibular ramus. If the mouth is wide open, this position would correspond with the occlusal surface of the upper molars. Here it divides into branches that ramify on the buccinator and go on to supply the mucous membrane of the cheek and the buccal gingiva from the second premolar to the third molar. Therefore, it appears that the most reliable location for anesthetizing the long buccal nerve would be at its most superficial location as it crosses the anterior border of the mandibular ramus. This position would be approximately where the point of needle penetration occurs for the Gow-Gates technique. If the anesthetic solution is injected immediately after needle penetration or just before withdrawal, the long buccal nerve would probably be anesthetized. Previous studies (2-4) reporting a higher success rate of buccal anesthesia may have deposited anesthetic solution either before or after reaching the target area, although the authors' descriptions in "Materials and Methods" did not indicate this. Since we followed the original author's technique (1), no anesthetic solution was deposited until the target area was reached and no solution was given upon withdrawal of the needle. Anatomically, we would recommend that a small amount of anesthetic solution be deposited upon initial needle penetration in the Gow-Gates technique to anesthetize the buccal nerve. This would also probably decrease the pain incidence as the target area is approached. The finding that some subjects did not respond to ice, even after a 15-s application, indicated that ice may not be as reliable as electric pulp testing, since all subjects initially responded to the EPT at a level below the maximum output (Table 1 and Fig. 1). The results of ice tests and EPT's (Table 1) showed that the EPT was more accurate in testing the degree of anesthesia. Several studies (17, 18) have shown that the tooth pulp is a reliable site for experimental algesimetry. Harris (19) stated that electricity is the stimulus of preference because it is precise and there appears to be no local reactions which might alter the response to subsequent stimuli. The results of the EPT's, 38% gave no response in the standard technique and 35% gave no response in the Gow-Gates technique, indicated that the majority of the subjects did not have complete anesthesia. Previous studies (2-6) have reported success rates for the Gow-Gates technique of over 90%. Robertson (3) reported a standard injection success rate of 71%. Wat-

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Montagnese et al.

Journal of Endodontics

son and Gow-Gates (2) and Gow-Gates and Watson (14) reported better than an 80% success rate for the conventional (standard) technique. Levy (5) reported a 65% success rate for the conventional technique. In most of these studies the response to routine dental treatment and extractions were the criteria used to evaluate the degree of anesthesia. The subjective interpretation of some of the patients' responses may have led to a higher success rate, i.e. anesthetic related discomfort may have been interpreted as nonanesthetic related discomfort. Another factor which may have accounted for a higher success rate, although significant only to a certain degree, was the lack of blind evaluation in these studies. The operator knew which injection he had given, which may have biased the results. Other factors affecting the degree of anesthesia in these studies would be the depth of cavity preparations, pulp pathosis, and the clinician. The lower success rate of the Gow-Gates technique, found in this study, may also have been related to the operator. Even though the senior author practiced the Gow-Gates technique prior to this study, he may not have been as technically proficient as previous researchers (2-5). The technique of palpating bone at the neck of the condyle was difficult to duplicate consistently using the external landmarks. The neck of the condyle was palpated approximately two-thirds of the time and in the other third of the injections, the needle was advanced to a maximum depth of 25 mm. However, the senior author, while possibly not as technically proficient with the Gow-Gates technique, still achieved a low rate of profound anesthesia (38%) with the conventional technique. The mean EPT value at 10 min after injection, 62 for the standard injection and 58 for the Gow-Gates technique, was higher than the initial EPT readings (Fig. 1). These mean values may indicate that routine operative procedures could be performed; however, profound anesthesia for endodontic procedures would be doubtful. The lack of profound anesthesia with both techniques, as evaluated with the electric pulp tester, is difficult to explain. Malamed (4) stated that there is a slower onset of anesthesia with the Gow-Gates technique. Usually the onset of clinically adequate anesthesia is 3 to 5 min, approximately the same as for the conventional technique. However, in some instances the onset of anesthesia may require 5 to 7 min. Levy (5) stated that the onset of complete anesthesia of the mandibular central incisor was 10 to 12 min with the Gow-Gates technique./~,gren and Danielsson (7) found that the onset of analgesia (EPT) could be delayed over 10 min in both techniques, even to 20, 30, and, in one case, up to 45 min. The longer time interval for anesthesia of the central incisor was explained by DeJong (20). He suggested that the nerves supplying distal structures occupied a

position in the central core of the nerve bundle, whereas proximal areas were supplied by nerves that were positioned peripherally. Therefore, the distal nerves would be the last anesthetized. ,~,gren and Danielsson (7) found that complete pulpal anesthesia (EPT) was more successful in the first bicuspid and second molar than in the central and lateral incisors at 10 min after injection in both the Gow-Gates and conventional techniques. In this study, 10 min postinjection was not an adequate time interval for complete anesthesia of the lateral incisor. It seems that a longer time interval is needed, regardless of the technique, for the onset of profound mandibular anesthesia. The amount of anesthesia (1.8 ml) used in this study may also help explain the results. Levy (5) found that the standard amount of solution, 1.8 ml, did not provide reliable third molar anesthesia. He, therefore, increased the amount to 3.0 ml in his study. Although he used 4% prilocaine without a vasoconstrictor, grade A anesthesia was achieved only 65% of the time with a standard injection. The Gow-Gates technique was 96% successful. However, as Levy (5) pointed out in his study, the operations were always started on the standard injection side, whereas the Gow-Gates side benefited from the increased knowledge of the procedure and increased time of anesthesia as the standard side was operated. Robertson (3) had a success rate of 92.6% with the Gow-Gates technique and 71% with the standard technique using 1.8 ml of local anesthetic solution. Malamed (4) reported a success rate of over 90% in the Gow-Gates technique. However, he used the Gow-Gates injection in 52% of the patients when the conventional technique failed to achieve adequate pain control. This would increase the amount of anesthetic solution for blocking nerve conduction and presumably the degree of anesthesia for that group of patients. In addition, no time intervals were given for evaluation of the onset of anesthesia in his study. It may be that a longer time interval, more than 10 min, elapsed before adequacy of clinical pain control was evaluated. ,~,gren and Danielsson (7) found no difference between the Gow-Gates technique and the conventional injection in achieving analgesia. They showed that complete pulpal analgesia, measured at 10 min, occurred in 71% of the teeth with the conventional technique and 52% of the teeth with the Gow-Gates injection. However, these results represented averages of complete analgesia in four teeth (mandibular centrals, laterals, first premolars, and second molars). The analgesia percentages for the mandibular centrals and laterals were much lower than the premolars and second molars. It is suggested that further studies be conducted to determine the optimal time to wait after either injection and to determine the optimal dose of local anesthetic solution to be used with these blocks. Another factor which may explain the lack of pro-

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found anesthesia in this study is accessory innervation. Frommer et al. (21), in an anatomical study, found that at least 20% of the mylohyoid nerve fibers were of small diameter. They speculated that these unmyelinated or thinly myelinated nerves may carry pain sensations. Chapnick (22), in a discussion of the nerve supply to the mandibular dentition, related that the mylohyoid nerve may enter the mandible between the bicuspids and may innervate the molars and bicuspids. He also discussed the possibility of the mylohyoid nerve entering the mandible on the lingual side of the symphysis below the genial tubercles, suggesting innervation by this nerve to the lower incisors. As stated by Malamed (4) and Levy (5), the mylohyoid nerve should be effectively blocked by the Gow-Gates injection. However, we found no difference between the GowGates technique and the standard injection when the lower lateral incisor was tested with the electric pulp tester. Chapnick (22) also discussed contralateral extension of the inferior alveolar and mylohyoid nerve across the midline to innervate the lower incisors. He also discussed the transverse or cutaneous coil nerve, a branch of the cervical plexus, which could possibly innervate the mandibular teeth. Although many of these nerves may provide innervation to the lower lateral incisor, which could explain our results, dentistry has either underestimated their importance or we have taken for granted the small amount of anesthetic solution used and the short time intervals for onset of anesthesia in the mandible. SUMMARY The purpose of this study was to compare the effectiveness of the Gow-Gates technique and a standard technique in attaining mandibular anesthesia. Forty subjects received both injections at separate appointments. The degree of anesthesia was evaluated after 10 min using various questions, sharp explorer tests, ice, and EPT's. The results demonstrated no significant differences between the two injection techniques except in response to the question concerning subjective tongue numbness. Both techniques achieved a high rate of subjective numbness in the subjects' perception of overall numbness and lip numbness. Objective testing showed that only 38% of the subjects in the

standard injection and 35% of the subjects in the GowGates technique gave no response to the electric pulp tester at the maximum output (80/80).
This paper was abstracted from Dr. Montagnese's thesis submitted to the Graduate School, The Ohio State University, in partial fulfillment of the requirements for the degree of Master of Science. The authors would like to thank Dr. Sam Rosen and Dr. Mike Beck for their help in the statistical analysis, and Ms. Linda Mihm, Ms. Anna Sinclair, and Ms. Jody White for assistance in the clinical portion of this study. Dr. Montagnese is in private practice, limited to endodontics, in Rocky River, OH. Dr. Reader is associate professor, Department of Endodontics. Dr. Melfi is professor and assistant dean, Department of Oral Biology. Address requests for reprints to Dr. AI Reader, Department of Endodontics, College of Dentistry, The Ohio State University, 305 W. 10th Ave., Columbus, OH 43210.

References
1. Gow-Gates GAE. Mandibular conduction anesthesia: a new technique using extraoral landmarks. Oral Surg 1973;36:321-30. 2. Watson JE, Gow-Gates GAE. A clinical evaluation of the Gow-Gates mandibular block technique. NZ Dent J 1976;72:220-3. 3. Robertson WD. Clinical evaluation of mandibular conduction anesthesia. Gen Dent 1979;27:49-51. 4. Malamed SF. The Gow-Gates mandibular block. Oral Surg 1981;51: 463-7. 5. Levy TP. An assessment of the Gow-Gates mandibular block for third molar surgery. J Am Dent Assoc 1981 ;103:37-41. 6. Yameda A, Jasstak JT. Clinical evaluation of the Gow-Gates block in children. Anesth Prog 1981 ;28:106-9. 7. ~,gren E, Danielsson K. Conduction block analgesia in the mandible. Swed Dent J 1981 ;5:81-9. 8. Bennett CR. Monheim's local anesthesia and pain control in dental practice. 5th ed. St. Louis: CV Mosby Co., 1974:17-49, 103-14. 9. Jorgensen NB, Hayden J. Sedation, local and general anesthesia in dentistry. 2rid ed. Philadelphia: Lea & Febiger, 1967:62-73. 10. Kleinknect RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973;86:842-8. 11. Kleinknect RA, Bernstein DA. The assessment of dental fear. Behav Ther 1978;9:626-34. 12. Malamed SF. Handbook of local anesthesia. 1st ed. St. Louis: CV Mosby Co., 1980:218. 13. Bartlett SZ. Clinical observations on the effect of injection of local anesthetic preceded by aspiration. Oral Surg 1972;33:520-6. 14. Gow-Gates GAE, Watson JE. The Gow-Gates mandibular block: further understanding. Anesth Prog 1977;24:183-9. 15. Sicher H, DuBrul EL. Oral anatomy. 5th ed. St. Louis: CV Mosby Co., 1970:317-8,359-65,410-21. 16. Anson BM. Morris' human anatomy, a complete systematic treatise. 12th ed. New York: McGraw-Hill Co., 1966:1032-5. 17. Harris SC, Brandel NE. The tooth pulp as an algesimetry site. J Dent Res 1950;29:68-72. 18. Harris SC, Blockus LE. The reliability and validity of tooth pulp algesimetry. J Pharmacol Exp Ther 1952;104:135-48. 19. Harris SC. Problems of experimental algesimetry. J Chronic Dis 1956;4:52-8. 20. DeJong RH. Physiology and pharmacology of local anesthesia. Springfield, IL: Charles C Thomas, 1970:118-22. 21. Frommer J, Mele FA, Monroe CW. The possible role of the mylohyoid nerve in mandibular posterior tooth sensation. J Am Dent Assoc 1972;85: 113-7. 22. Chapnick L. Nerve supply to the mandibular dentition. A review. J Can Dent Assoc 1980;46:446-8.