Anesthesia and Pain Control

DART
Two hours of CDE credit

Periodontal ligament injection: Review and recommended technique

James S. Dower Jr., DDS, MA | Zuri M. Barniv, DDS

The periodontal ligament (PDL) injection is used primarily when conventional anesthesia is not fully effective, when dentists require only a short duration of anesthesia, and when a patient wants to avoid the lip and tongue numbness associated with mandibular block injections. To provide effective anesthesia and to lessen adverse reactions associated with the injection, it is important to understand the proper technique for administering a PDL injection. This article provides a literature review of the PDL injection and a review of the authors techniques, including indications and contraindications, patient considerations, site and syringe preparation, administration of the injection, and possible postoperative effects. Received: April 20, 2004 Accepted: June 28, 2004

Indications
The PDL injection is useful when conventional anesthesia is not fully effective. In addition, one study found that 74% of patients preferred the PDL injection for primary anesthesia rather than standard anesthesia techniques.1 The injection is beneficial for patients who require anesthesia for a short duration (~20 minutes), when highly localized anesthesia is necessary to diagnose the source of pain, and when a patient wants to avoid the lip and tongue numbness associated with mandibular block injections.4 Limiting anesthesia to the site of treatment without causing the lip and tongue to feel numb also is beneficial for young children and developmentally delayed patients who might bite and chew on the anesthetized areas, causing considerable damage.1,5 PDL injections also offer benefits to hemophiliacs, immunocompromised patients, and pregnant women.5 For hemophiliac patients, the PDL injection is preferable to block injections, which can lead to excessive bleeding. Although local anesthetics and vasopressors are not teratogens and can be administered safely to pregnant women during all three trimesters, it is prudent to administer the smallest necessary amount of any drug to these patients.1,4 The PDL injection would be beneficial for pregnant women only if the total dose of local anesthetic was significantly less than the dose administered using a standard injection technique. Therefore, the operator would need to consider the duration of anesthesia needed and the total amount of solution that would be utilized with standard injection techniques. When considering the PDL injection with pregnant patients, it also is important to check for adverse periodontal conditions that are associated with pregnancy. A consultation with the pregnant patients physician also is recommended prior to providing local anesthesia.1

In textbooks published between 1912 and 1923, the periodontal ligament (PDL) injection, also known as the intraligamentary injection, was described as the peridental injection.1 During the 1980s, the majority of articles pertaining to PDL injections began to appear, due to a resurgence of interest in the technique.2 Although a standard syringe was primarily used for the injection, it was difficult to express solution into the dense PDL space, as compared to the ease of expressing solution in most other injections. The difficulty in expressing local anesthetic into the PDL space is similar to the difficulty in expressing solution into the attached gingiva of the palate. Currently, there are three types of syringes that can be used to inject anesthesia into the PDL: a standard syringe, specialized PDL syringes with a mechanical advantage, and systems that offer mechanical assistance with metered flow rates. The standard syringe comes in Astra or Cooke-Waite styles, while the specialized PDL syringes come in pistol or pen types. The Wand (Milestone Scientific, Livingston, NJ; 800.862.1125) and Comfort Control (Dentsply Professional, Des Plaines, IL; 800.800.2888) are metered flow rate anesthesia systems that overcome tissue resistance. During a PDL injection, the resistance to solution flow into the PDL space and the forces exerted on the rubber stopper by the syringe create high pressure with-

in the cartridge; this pressure can cause the cartridge to rupture. PDL syringes and automated dispensing systems offer a significant mechanical advantage for dispensing anesthetic but these greater forces also may increase the chance of cartridge rupture. Due to this additional risk, specialized syringes have casings or tubes that fully contain the cartridge in the event of a rupture. Standard syringes, by comparison, are only partially encased and contain openings designed to allow the operator to do a visual aspiration test. Most syringes have two such openings on either side of the encasement, with one larger than the other. In the unlikely event that a cartridge ruptures, it would be important to have the smaller of the two openings facing the patient, minimizing the risk of injury. There are two types of specialized PDL syringes: the pistol-type and the pen-type. The pistol-type syringe offers excellent mechanical reliability, reasonable cost, and clinical effectiveness. According to Smith et al, the pistol-type syringe provides anesthesia 83% of the time when used properly.3 The pen-type PDL syringe is useful when it is important to avoid instruments that look intimidating, such as when working with pediatric patients. Although the pen-type syringe appears less intimidating, the authors have found it to be less stable, less durable, and less reliable than the pistol-type syringe.

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Fig. 1. During a PDL injection, local anesthetic flows through the cribriform plate of the root socket into the blood-filled spaces of the alveolar bone. Adapted with permission of Ronvig, Inc.

Fig. 2. The porosity of the cribriform plate of the tooth socket allows the local anesthetic to flow from the PDL into the alveolar bone.

The PDL injection also is beneficial when performing bi-mandibular procedures so that both sides of the patients lip and tongue do not have the dysfunctions associated with mandibular block injections. Current evidence suggests that there is no additional susceptibility to dry socket when the PDL injection is used for tooth extraction. Since the PDL injection usually anesthetizes only the tooth, adjacent bone, and soft tissue, patients may not sense that they are anesthetized, especially in the mandible, where they may be accustomed to exaggerated symptoms of lip and tongue numbness following a block injection. Before the dental procedure begins, it is important to demonstrate to patients that the area to be treated has been anesthetized.

minor and temporary changes in the occlusion of the anesthetized tooth; therefore, it is not recommended when cementing crowns or when accurate occlusion is a major consideration. The PDL injection also is contraindicated for primary teeth when the injection may damage developing crowns of underlying permanent teeth.1,4,6 Although several studies have used epinephrine concentrations as high as 1:50,000, vasoconstrictors with concentrations of more than 1:100,000 epinephrine should be used with caution due to the higher risk of ischemic necrosis of adjacent tissue and cardiac symptoms.2,7-9 For a patient with moderate to severe medical conditions that might be exacerbated by vasoconstrictors, a conventional injection with or without vasoconstrictor would be safer than a PDL injection with vasoconstrictor.

the tooth socket. The honeycombed configuration of the mandible and maxilla appear on radiographs as a trabeculation pattern. Once the local anesthetic enters the blood-filled spaces of the mandible or maxilla, it spreads to the innervation of the adjacent tooth/teeth and into the systemic circulation.12 This pathway of the local anesthetic solution from a PDL injection has been demonstrated in baboons by using radiopaque markers.13 Once the anesthetic enters the marrow spaces of the mandible or maxilla, it is absorbed rapidly into the systemic circulation in a manner similar to a direct intraosseous injection, resulting in systemic effects that resemble an intravascular injection.10 This is an important point to remember when considering administering the injection to patients who are medically compromised or are hyperresponders to the vasoconstrictor in local anesthetics. Although Cannell et al stated in 1993 that intraligamentary injections administered properly are unlikely to cause any systemic effects, the authors have noted some patients displaying cardiac responses to the epinephrine in local anesthetics that have a 1:100,000 epinephrine concentration.14

Effectiveness and duration of anesthesia

The effectiveness and duration of anesthesia from a PDL injection is linked most closely with the use of a vasoconstrictor with the local anesthetic. Most of the articles cited used 0.2 mL of local anesthetic at the injection site. One 1988 study reported that the PDL injection produced profound anesthesia 75% of the time in the molar region, 58% of the time in the premolar region, and 39% of the time for lateral incisors.15 Kim achieved profound anesthesia 88% of the time with 2% lidocaine with 1:50,000 epinephrine, 81% of the time with 2% lidocaine with 1:100,000 epinephrine, and only 3.8% of the time with 3% mepivacaine without vasoconstrictor.8 In 1987, Gray et al reported a 91.6% success rate in achieving profound anesthesia when the local anesthetic contained 1:80,000 adrenaline vasoconstrictor.16 Childers et al reported that the injection technique and location influenced duration of anesthesia, while Kaufman et al reported that PDL injections of 2% lidocaine with

Contraindications
Sites with moderate to severe gingival infection, such as acute necrotizing ulcerative gingivitis (ANUG), periodontal abscess, or severe periodontitis, are contraindicated for the PDL injection. This is because the penetration site is inside the periodontal sulcus, forcing the needle to penetrate the gingival attachment.1,6 The trauma of the injection would have a negative impact on inflamed or infected tissue; more importantly, bacteria and bacterial agents would spread with the solution through the PDL and into the maxillary and mandibular bone. The PDL injection is associated with

Mechanism of action
The PDL injection has a mechanism of action similar to an intraosseous injection and may mimic an intravascular injection.10,11 Solution injected into the PDL space follows the path of least resistance laterally through the porous cribriform plate of the boney tooth socket into the blood-filled spaces of the mandible or maxilla (Fig. 1). Because of the expressed solutions movement through the ligament and into osseous tissue, some authors refer to the injection as a transligament injection.2 Figure 2 shows the porous cribriform plate of

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Table. Information patients should be aware of prior to PDL injection.

Transient heart palpations or other cardiac responses may result; these should dissipate within minutes Be prepared for postoperative sensitivity and hyperocclusion for up to 48 hours after the injection Patients might taste the bitterness of the anesthetic that is being deposited in the sulcus before the needle penetrates tissue This injection technique may cause patients to feel significant pressure but rarely will they feel pain as the solution is being deposited in the tissue; the injection likely will feel like a comfortable probing
Fig. 3. A 30-gauge short needle bent at the hub with the bevel of the needle directed toward the cribriform plate of the root socket.

1:50,000 epinephrine produced a mean duration for profound anesthesia of 27.05 minutes and a range of 067 minutes.17,18 In the report by Kaufman et al, 2% lidocaine without epinephrine had a mean duration of 1.05 minutes anesthesia and a range of 02.5 minutes.18 In that same report, a review of the literature indicated that most studies report duration of anesthesia centering on 20 minutes. Dentists might assume that longeracting anesthetics would result in a longer period of anesthesia; however, 0.5% bupivacaine with 1:200,000 epinephrine and 1.5% etidocaine with 1:200,000 epinephrine do not provide hard tissue anesthesia of longer duration in the maxilla with either PDL or standard anesthesia techniques. Compared to the use of 2% lidocaine with 1:100,000 epinephrine, they also do not provide a longer period of anesthesia when administered by PDL injection to the mandibular teeth.19 Schelder et al reported that 2% lidocaine with 1:100,000 epinephrine provided longer anesthesia than either 2% lidocaine without epinephrine or 3% mepivacaine without vasoconstrictor.20 A 1985 study by Johnson et al found that 2% lidocaine with 1:100,000 epinephrine produced effective anesthesia for 17.3 minutes ( 4.5 minutes) and reported that epinephrine concentration was more important than any other factor.21

reviewed for susceptibility to subacute bacterial endocarditis (SBE) or sensitivity to epinephrine. It is important to remember that a PDL injection is likely to cause a bacteremia and that antibiotic prophylaxis is required for patients who are susceptible to SBE when a PDL injection is administered.1 Because this recommendation may change, dentists are advised to check the American Heart Association guidelines for the prevention of bacterial endocarditis. Patients who are not at risk for SBE do not need premedication for the PDL injection. The dentist should inform the patient that transient heart palpitations or other cardiac responses may result from the injection, which should dissipate within two to five minutes. Patients who are unaware of this potential side effect may be alarmed if they notice a change in heart function. This unexpected experience may subsequently cause a release of additional catecholamines, further exacerbating the heart response. Table 1 lists additional information the patient should be aware of prior to injection.

Syringe preparation
For the PDL injection, dentists may use a standard syringe, a PDL syringe, or an automatic-dispensing syringe. It is very difficult to express the solution from a standard syringe; as a result, dispensing the one-quarter cartridge recommended here will take significant time and exertion. The effort and time required to give an adequate PDL injection with a standard syringe will vary depending on the individual practitioner; some practitioners may not have the necessary hand strength required to give the injection at all, while others may be able to dispense the recommended one-quarter cartridge

Patient preparation
When preparing a patient for a PDL injection, it is advisable to check the periodontal health of the gingival sulcus that will receive the injection. Active periodontal disease, periodontal abscesses, and ANUG are all contraindications for injecting into deep periodontal pockets. The patients medical history should be

in less than one minute. It also should be noted that although it is easier and faster to administer the solution with the specialized PDL syringes (~30 seconds), it still requires effort and time. When using a standard syringe, the dentist should be sure to face the syringes larger opening to monitor the amount of anesthetic deposited. A 27gauge or 30-gauge extra-short needle (Fig. 3) is recommended for the PDL injection because these needles are shorter and stiffer; as a result, they seldom bend when forces are applied to push the needle into the PDL. Regardless of the type of syringe, the bevel of the needle should be pointed away from the tooth and toward the alveolar bone to facilitate the flow of solution through the cribriform plate of the tooth socket. Bending the needle at the hub so that it is almost perpendicular to the syringe body, similar to how a periodontal probe tip is angled from the handle, will improve access to the posterior of the mouth (Fig. 3). A bent needle should not be re-bent nor should it be straightened and reused for a second injection since doing either increases the risk of breaking the needle at the bend. When a standard syringe is used, some dentists express anesthetic prior to injection so that the thumb-ring is in a comfortable position when they apply the heavy forces necessary for the injection. With the specialized PDL syringes, the internal piston needs to be advanced to the rubber stopper before the injection is administered so that solution is expressed when the syringe lever is first activated. Aspiration is not necessary for the PDL injection, as the needle is unlikely to enter any major blood vessels.

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Fig. 4. To reduce the amount of tooth accumulative materials that might be injected into the PDL, the tooth surface is debrided.

Site preparation
The authors believe that most cases of moderate to severe postoperative pain and complications from PDL injections result from debris, plaque, and/or calculus on the tooth being incorporated into the injected solution. The authors theorize that when the needle slides along the tooth on its way to the sulcus and the orifice of the needle collects these various tooth accumulative materials, they are injected into the ligament space. The authors have noted that debriding tooth surfaces prior to PDL injections (Fig. 4) significantly reduces the amount and intensity of postoperative pain and complications. It is recommended that any calculus or plaque be removed prior to injecting, especially during an emergency visit when the patient may not have had a prophylaxis for some time. Sliding the needle directly into the sulcus like a periodontal probe minimizes trauma to the gingiva by the needle.

Injection technique
The bevel of the needle should face away from the tooth and toward the bone. The penetration site and the area of the tooth the needle will contact are debrided. Because innervations generally originate from the distal, single-rooted teeth should receive the injection at the distal surface while multi-rooted teeth should receive injections at both the mesial and distal surfaces. Dentists may require an indirect finger rest or the elbow of the arm for holding the syringe against their side to ensure stability. The needle should engage the PDL in the gingival sulcus just below the tooth contact. To minimize or eliminate the discomfort of the initial penetration, drops of anesthetic should be administered for 10 seconds after the sulcus is en-

tered but before the attachment is penetrated. The needle is placed gently against the attachment in a manner similar to a probing and more drops of solution are administered over a span of approximately five seconds. These steps take an additional 15 seconds total and not only make the injection more comfortable but also help to prevent tooth accumulative materials from being injected into the gingival attachment, as discussed previously. At this point, the attachment is penetrated gently and the anesthetic is deposited slowly; this usually takes another two to three seconds. The needle advances apically into the PDL space but will not be able to penetrate further as it is wedged between the root of the tooth and the bony tooth socket. Approximately one-quarter cartridge of solution (0.45 mL) should be deposited at each location to provide an acceptable level of anesthesia. Most of the references listed in this article recommend dispensing 0.2 mL of local anesthetic at each injection site. Between 1999 and 2004, the authors used 0.45 mL with a N-Tralig syringe (Miltex, York, PA; 800.645.8000) on more than 750 patients with little or no negative operative or postoperative effects. For those who wish to dispense in increments of 0.2 mL, the authors recommend using the rubber stopper in a 1.8 mL cartridge as a reference. This volume of anesthetic is the approximate distance of one stopper length. If a specialized PDL syringe is used, the authors recommend depositing the quarter-cartridge of solution within approximately 30 seconds. The authors also theorize that the more rapidly the solution is deposited into the PDL, the more the PDL will be disrupted, which may cause postoperative discomfort. It is likely that a standard syringe will take longer to deposit this amount of solution due to the PDLs extreme resistance to the solution. This extreme resistance is one of the indicators that the injection has been performed correctly with proper positioning of the needle into the sulcus; if there is no overflow of solution from the sulcus once the ligament is penetrated completely, it is another indicator that the injection was performed correctly. Any overflow should be removed using suction. The injection has little

chance of success if the solution is easy to express or if solution is seen flowing out of the sulcus. These signs indicate the solution is not being injected into the PDL space. The tissue adjacent to the injection site often will blanch as a result of the vasoconstrictor and/or the pressures within the tissue from the deposited solution. Dentists should consider giving patients a preoperative rinse (in combination with a mouthwash) to counter the taste of any local anesthetic that may flow out of the sulcus.

After the injection

As mentioned, the tissue at the injection site may be blanched. Any anesthetic administered prior to penetrating the attachment and/or any that leaked out during the injection should be rinsed from the patients mouth. In addition, the dentist should address concerns regarding a patients heart response to the vasoconstrictor; if the patient experiences any heart response, assure him or her that it rarely lasts more than five minutes.1 A bent needle that is no longer going to be used should be straightened before recapping; an attempt to recap it completely may cause the needle to penetrate through the plastic covering, creating a needle-stick hazard. Also, needles that have been bent and then re-bent should not be used because they could break. Anesthesia should be profound within one minute.22,23 If anesthesia still is insufficient, another PDL injection can be administered; however, the tissue may necrose if it is blanched for extended periods due to prolonged restricted blood flow. Due to the fact that the PDL injection provides anesthesia for a limited duration, dental treatment must be completed as efficiently as possible, especially in areas that were resistant to anesthesia prior to the injection. Once the injection is completed, work can begin almost immediately since the anesthetic takes effect in less than one minute.22,23 Patients are accustomed to waiting for anesthesia to take effect and experiencing peripheral altered sensation once the area is sufficiently anesthetized, especially with mandibular block injections. As a result, the area should be tested to reassure the patient that they are anesthetized. A percussion test that compares the tooth that

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is being treated to another tooth that is not anesthetized usually is sufficient. Soft tissue can be tested in a similar manner using the curved portion of the dental explorer.

Postoperative effects
It is important to remember that the occlusion may temporarily be high and that the patient may detect the change. Postoperative discomfort may follow anesthesia but that usually is limited to the first 1248 hours.20,24 According to a 1988 study by White et al, approximately 86% of patients experience some symptoms after one day. Of those, 36% report a high level of pain.15 Four years later, McLean et al reported that only 25% of subjects reported some degree of postoperative discomfort, with high occlusion being the most common complaint.19 The amount of postoperative discomfort following a PDL injection usually is greater than pain from traditional local infiltration.17 A 1984 study involving baboons demonstrated that the actual damage caused by a PDL injection is localized, minor, and reversible.25 In most cases, a slight inflammatory reaction and hyalinization adjacent to areas receiving the injection begins 24 hours postinjection and all signs of damage disappear after eight days. When granulation tissue forms, it usually occurs in 15 days and does not damage bone or cementum.25 Malamed reports that such damage is due to needle penetration rather than the anesthetic agent itself, although the authors believe anesthetic extruded through the PDL also can have a harmful effect on the tissue.1 A 1990 study involving dog teeth reported that the PDL injection may cause localized external root resorption in very rare cases.9 Prolonged ischemia of the interdental papilla may be followed by sloughing and exposure of crestal bone, usually because the dentist injected too rapidly, utilized too much solution, or reinjected too many times, resulting in extended tissue blanching.1 Other than rare cases of root resorption, almost all damage resolves completely in less than 25 days.1 At present, no studies have reported long-term damage to pulpal tissue as a result of PDL injections.24 A 1990 study reported that any pulpal reaction is related mostly to the depth of the cavity

preparations rather than to the actual PDL injection itself.26 In some cases, there is no clinically apparent postoperative pulpal or periodontal damage at all.19 Long-term studies on dog teeth have confirmed that the PDL injection has no effect on the pulp.9

Summary
The PDL injection is a safe and useful method for achieving localized, immediate, and profound anesthesia during a relatively short period. The injection is indicated when anesthesia with traditional techniques is insufficient, when anesthesia of a short duration is needed, when near-instant anesthesia is desired, when a highly localized injection is needed, where an absolute minimum volume of anesthetic is indicated, and when a hemophiliac patient requires an alternative to a block and/or infiltration injection. The injection is contraindicated when the penetration site is severely inflamed or infected, when accurate assessment of occlusion is necessary, when primary teeth are involved, and when patients are unable to receive vasoconstrictors. The studies reviewed in this article indicate clearly that the use of vasoconstrictor containing local anesthetics is essential for acceptable depth and duration of anesthesia; 2.0% lidocaine with 1:100,000 epinephrine appears to be the anesthetic of choice. The best predictors for a successful PDL injection are a high resistance to solution flow and no signs of solution flowing out of the sulcus. Most postoperative symptoms are localized, transient, and minor. The most common symptom is the sensation of high occlusion. At present, there is no evidence that the injection causes any pulpal damage. Considering the limited duration of anesthesia provided by the PDL injection and that the injection is used primarily when the tooth has received inadequate anesthesia (even though the lip sensation indicates the mandibular alveolar is anesthetized), dentists must consider carefully which option to take in these situations. If the required duration of anesthesia is more than that provided by a PDL injection, dentists should focus on profound mandibular alveolar anesthesia. It is important to remember that the mandibular alveolar is not anesthetized completely until the patients lip symp-

toms are consistent with profound mandibular alveolar anesthesia; for most patients, these symptoms involve the sensation of a swollen or thickened lower lip to the midline. If a dentist needs no more than 15 minutes of anesthesia, the PDL injection could be utilized; otherwise, the mandibular block injection should be pursued until the patient has lip symptoms consistent with profound anesthesia.

Author information
Dr. Dower is an associate professor, Department of Restorative Dentistry and director of the local anesthesia curriculum, University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, California. Dr. Barniv is an assistant professor, Department of Dental Practice at University of the Pacific Arthur A. Dugoni School of Dentistry, and clinic director of the Union City Dental Care Centers Advanced Education in General Dentistry Residency program in Union City, California.

References
1. Malamed SF. Handbook of local anesthesia, ed. 4. St. Louis: C.V. Mosby;1997:120223. 2. Kaufman E. Transligamentary anesthesia: A review. Anesth Pain Control Dent 1992; 1:133-141. 3. Smith GN, Walton RE, Abbott BJ. Clinical evaluation of periodontal ligament anesthesia using a pressure syringe. J Am Dent Assoc 1983;107:953-956. 4. Miltex Instrument Company. N-Tralig Syringe [instructions]. York, PA: Miltex Instrument Company, Inc.;2004. 5. Malamed SF. The periodontal ligament (PDL) injection: An alternative to inferior alveolar nerve block. Oral Surg 1982;53: 117-121. 6. Quilici DL. Contraindications in the use of the periodontal ligament injection. Compend Contin Educ Dent;11:96-100. 7. Gray RJM, Lomax AM, Rood JP. Periodontal ligament injection: Alternative solutions. Anesth Prog 1990;37:293-295. 8. Kim S. Ligamental injection: A physiological explanation of its efficacy. J Endod 1986;12:486-491. 9. Roahen J, Marshall FJ. The effects of periodontal ligament injection on pulpal and periodontal tissues. J Endod 1990;16:28-33. 10. Pashley D. Systemic effects of intraligamental injections. J Endod 1986;12:501-504. 11. Smith GN, Walton RE. Periodontal ligament injection: Distribution of injected solutions. Oral Surg Oral Med Oral Pathol 1983;55: 232-238.

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12. Walton RE. Distribution of solutions with the periodontal ligament injection: Clinical, anatomical, and histological evidence. J Endod 1986;12:492-500. 13. Garfunkel AA, Kaufman E, Marmary Y, Galili D. Intraligamentaryintraosseous anesthesia. A radiographic demonstration. Int J Oral Surg 1983;12:334-339. 14. Cannell H, Kerawala C, Webster K, Whelpton R. Are intraligamentary injections intravascular? Br Dent J 1993;175:281-284. 15. White JJ, Reader A, Beck M, Meyers WJ. The periodontal ligament injection: A comparison of the efficacy in human maxillary and mandibular teeth. J Endod 1988;14:508-514. 16. Gray RJ, Lomax AM, Rood JP. Periodontal ligament injection: With or without a vasoconstrictor? Br Dent J 1987;162:263265. 17. Childers M, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the periodontal ligament injection after an inferior alveolar nerve block. J Endod 1996;22:317320.

18. Kaufman E, LeResche L, Sommers E, Dworkin SF, Truelove EL. Intraligamentary anesthesia: A double-blind comparative study. J Am Dent Assoc 1984;108:175-178. 19. McLean ME, Wayman BE, Mayhew RB. Duration of anesthesia using the periodontal ligament injection: A comparison of bupivacaine to lidocaine. Anesth Pain Control Dent 1992;1:207-213. 20. Schleder JR, Reader A, Beck M, Meyers WJ. The periodontal ligament injection: A comparison of 2% lidocaine, 3% mepivacaine, and 1:100,000 epinephrine to 2% lidocaine with 1:100,000 epinephrine in human mandibular premolars. J Endod 1988; 14:397-404. 21. Johnson GK, Hlava GL, Kalkwarf KL. A comparison of periodontal intraligamental anesthesia using etidocaine HCl and lidocaine HCl. Anesth Prog 1985;32:202-205. 22. Mansour MS, Adawy AM. The periodontal ligament injection. Egypt Dent J 1985;31: 109-119.

23. McCreary C. Intra-ligamentous anesthesia utilizing the Citoject syringe. J Ir Dent Assoc 1986;32:13-16. 24. Walton RE. The periodontal ligament injection as a primary technique. J Endod 1990;16:62-66. 25. Galili D, Kaufman E, Garfunkel AA, Michaeli Y. Intraligamentary anesthesiaA histological study. Int J Oral Surg 1984;13: 511-516. 26. Plamondon TJ, Walton R, Graham GS, Houston G, Snell G. Pulp response to the combined effects of cavity preparation and periodontal ligament injection. Oper Dent 1990;15:86-93. To order reprints of this article, contact Donna Bushore at 866.879.9144, ext. 156 or dbushore@fostereprints.com.

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Exercise No. 149 Subject Code: 132 Anesthesia & Pain Control The 15 questions for this exercise are based on the article, Periodontal ligament injection: Review and recommended technique, on pages 537542. This exercise was developed by William U. Wax, DMD, FAGD, in association with the General Dentistry DART Committee.

Reading the article and successfully completing this exercise will enable you to: be aware of the types of syringes available to perform periodontal lig
ament (PDL) injections; understand the indications and contraindications for PDL injections; be aware of the type of solutions to use for PDL injections; know needle placement locations for PDL injections; and be familiar with possible effects the patient may experience during and after PDL injections.

DART

Answer form and instructions are on pages 527528. Answers for this exercise must be received by November 30, 2005.

1. A PDL injection can be used only as an adjunct to block or infiltration analgesia. PDL injections were described originally in the literature as the periodontal injection. A. Both statements are true. B. The first is true; the second is false. C. The first is false; the second is true. D. Both statements are false. 2. Which type of syringe is not used in PDL injections? A. Standard B. Mechanical advantage C. Metered flow D. CO2 cartridge 3. Which of the following are indications for PDL injections? 1. Ineffective infiltration or block injections 2. Procedures of an hour or more in duration 3. Diagnosis of pain source 4. Immunocompromised patients A. 1, 2, and 3 only B. 1, 2, and 4 only C. 1, 3, and 4 only D. 2, 3, and 4 only 4. Which of the following are contraindications for PDL injections? 1. History of dry socket 2. ANUG 3. Severe periodontitis 4. Crown cementation A. 1, 2, and 3 only B. 1, 2, and 4 only C. 1, 3, and 4 only D. 2, 3, and 4 only 5. Patients may experience cardiac symptoms following a PDL injection. The duration of anesthesia depends more on the vasoconstrictor in the carpule rather than on the type of local anesthetic. A. Both statements are true. B. The first is true; the second is false. C. The first is false; the second is true. D. Both statements are false.

6. Which of the following can be associated with PDL injections? 1. Postoperative sensitivity 2. Catecholamine release 3. Bacteremia 4. Hyperocclusion A. 1, 2, and 3 only B. 1, 2, and 4 only C. 2, 3, and 4 only D. 1, 2, 3, and 4 7. Which of the following factors is a concern when administering PDL injections? A. Syringe type B. Sulcus depth C. Bevel direction D. Aspiration prior to injection 8. Most cases of moderate to severe postoperative pain or complications from PDL injections may be a result of 1. pressure from the injection. 2. PDL inflammation from material introduced by the injection. 3. direction of the needle during the injection. 4. supra-occlusion resulting from the PDL injection. A. 1 and 2 only B. 1 and 3 only C. 2 and 4 only D. 3 and 4 only 9. Which of the following structures is not a concern during a PDL injection? A. Attached gingiva B. Periodontal ligament C. Gingival sulcus D. Cribiform plate 10. When performing a PDL injection, the needle bevel should face the tooth. The needle bevel should be placed into the sulcus perpendicular to the long axis of the tooth at the distofacial line angle. A. Both statements are true. B. The first is true; the second is false. C. The first is false; the second is true. D. Both statements are false.

11. How much anesthetic do the authors recommend for each injection site after reaching the proper injection location? A. 0.15 mL B. 0.25 mL C. 0.35 mL D. 0.45 mL 12. Which of the following is recommended upon completion of injection? 1. Mouth rinsing by patient 2. Reassurance by the dentist if cardiac symptoms have arisen 3. Begin dental treatment 4. Test for numbness A. 1, 2, and 3 only B. 1, 2, and 4 only C. 1, 3, and 4 only D. 2, 3, and 4 only 13. Of those who report postoperative discomfort, the most common complaint is A. sensitivity to heat and cold. B. high occlusion. C. swelling of the gingiva. D. a burning sensation. 14. Pulpal effects of a PDL injection are A. nonexistent. B. reversible. C. of short duration. D. of long duration. 15. Which of the following is predictive of a successful PDL injection? A. A numb feeling B. Resistance to solution flow during the injection C. Overflow of solution into the oral cavity D. Use of an anesthetic solution without the vasoconstrictor

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