Adjuncts to Local Anesthesia: Separating Fact from Fiction

Jason K. Wong, DDS

Abstract
Adjunctive local anesthetic techniques and their armamentaria, such as intraosseous injection, computer-controlled delivery systems, periodontal ligament injection and needleless jet injection, have been proposed to hold particular advantages over conventional means of achieving local anesthesia. This article describes the use of each technique and proprietary armamentarium and reviews the literature appraising their use. MeSH Key Words: anesthesia, dental/methods; anesthesia, local/methods; equipment design
! "an #ent Assoc $%%&; '()*+&-( This article has been peer reviewed.

The achievement of successful local anesthesia is a continual challenge in dentistry. Adjunctive local anesthetic techniques and their armamentaria are often marketed to clinicians as a panacea, but they are not ithout their o n disadvantages and complications. Such techniques and equipment include intraosseous !"#$ injection systems, computer%controlled systems for delivery of local anesthetic, periodontal ligament !&D'$ injection and needleless jet%injection systems. The purpose of this article is to revie the niche applications of these techniques and to summari(e the scientific literature appraising their use.

Defining Success in 'ocal Anesthesia

Success rates for local anesthetic techniques are critically dependent on the particular criteria used to define success. )uoted rates may be misleading or meaningless if they do not state the specifics of the particular stimuli, teeth and pulpal states involved. &ulpal anesthesia as evaluated by standard electrical pulp testing !*&T$ criteria has provided a consistent basis for elucidating the value of traditional approaches to local anesthesia as ell as the benefits of adjunctive techniques.+ Despite subjective lip numbness, success rates for pulpal anesthesia in vital asymptomatic mandibular first molars after conventional inferior alveolar nerve block !"A,-$ are poor, averaging ./0 even after deposition of up to 1.. m' of local anesthetic2%3 !see Table 1 Success rates for conventional inferior alveolar nerve block, $. "n mandibular first molars ith irreversible pulpitis, success rates are even orse, averaging 1405,/ !see Table !, Success rates for conventional inferior alveolar nerve block in patients ith irreversible pulpitis, $.

Subjective lip numbness is a poor indicator of local anesthetic success as assessed by *&T.

6easons for 7ailure of 8onventional 'ocal Anesthetic Techniques

7actors contributing to the failure of conventional local anesthetic techniques must be considered before e9amining the rationale for any local anesthetic adjunct. These factors can be broadly classified as related to the armamentarium, the patient and the operator !see Table ", 6easons for failure of conventional anesthetic techniques, $ . Armamentarium%related factors such as deflection of the needle tip have been suggested to result in inaccurate needle placement and higher failure rates ith "A,-.+4 :o ever, even ith accurate placement, the unpredictable spread of local anesthetic solution may contribute to failure.++ &atient%related factors include anatomical factors such as cross%innervation in the mandibular incisor region+2 and accessory innervation in the mandibular posterior region !by the lingual, long buccal and mylohyoid nerves, for e9ample$, hich may allo nociceptive inputs despite complete "A,-. The thick corte9 of the mandible and the (ygomatic process of the ma9illa impede diffusion of anesthetic solution and may result in local anesthetic failure. "ntravascular injection invariably results in failure. &athological states such as the presence of pulpal inflammation are associated ith higher rates of failure of local anesthesia.+1 #perator%related factors such as ine9perience and poor technique may also contribute to failure. 7or e9ample, unfamiliarity ith the ;o %;ates mandibular block may lead the operator to inadvertently allo the patient to close his or her mouth and inappropriately displace critical anatomical targets such as the neck of the condyle out of the trajectory of the needle. The reader is encouraged to refer to the comprehensive revie articles discussing this subject,+4%+1 hich is beyond the scope of the current article.

"ntraosseous "njection
"# injection is the introduction of local anesthetic directly into periradicular cancellous bone. The rationale is that efficacy ill be increased by minimi(ing or eliminating armamentarium, patient and operator%related factors contributing to failure of traditional nerve block. "# injection is not a ne concept, and its evolution has resulted in convenient prepackaged kits !see Table #, 8omparison of various systems for adjunctive local anesthesia, http<== .cda%adc.ca=jcda=vol%.3=issue%3=1/+.html > Figs. 1 , !a !b !c !d "a "b $ marketed under the names :ypo !?&' Technologies, 7ranklin &ark, "'$, Stabident !7airfa9 Dental, ?iami, 7'$ and @%Tip !@%Tip Technologies, 'ake ood, ,A$.

"# injection has been purported to result in greater success of anesthesia, more rapid onset of anesthesia, and less residual soft%tissue anesthesia> it is apparently less painful and reportedly allo s use of lo er doses than are needed for conventional nerve block techniques. "n virtually all studies investigating these claims !and cited in the follo ing paragraphs$, the Stabident system has been arbitrarily selected for analysis. Bhen used to supplement failed primary "A,-, "# injection has reliably increased success2,C%.,5,/,+3 !see Table $, Success rates for conventional inferior alveolar nerve block ith supplemental intraosseous injections, and Table %, Success rates for conventional inferior alveolar nerve block ith supplemental intraosseous injection in irreversible pulpitis,http<== .cda%adc.ca=jcda=vol%.3=issue%3=1/+.html "n the cited studies, success as defined as no response to ma9imal *&T output !54 readings$ on 2 consecutive tests .4 minutes after application of the anesthetic. Supplemental "# injection improved the average success rate to /30 in vital asymptomatic mandibular first molars2,C,D,.,+3 !Table $$ and to 510 in first molars ith pulpitis5,/ !Table %$. :o ever, anesthesia declined to as lo as 3.0 after one hour.+2 "# injection is less successful as a primary technique in mandibular first molars, for hich success rates average 3D0+5,+/ and decline steadily ith time to less than D40 after one hour.+5 This method appears to have no advantages over "A,- as a primary means to achieve anesthesia. 8laims that anesthesia is immediate are fairly consistent ith clinical findings. #nset of anesthesia has been ithin one minute after injection and therefore can be deemed rapid, if not immediate.2,C,. ?a9imal discomfort as rated as mild to moderate pain and occurred on insertion of the needle for infiltration before perforation, rather than during the perforation itself ! hich as rated as causing no discomfort or as mildly painful$.+5 This effect is attributed to the absence of sensory innervation in cortical bone, in contrast to the richly innervated periosteum.+5 The duration of anesthesia is less ith plain solutions than ith vasoconstrictor.2,+/ According to the single study available, there appears to be less soft%tissue anesthesia !C20$ ith primary "# injections compared to "A,-.+5 8laims have been made that reducing the volume of local anesthetic injected does not affect the success rate of the "# approach. #nly the supplemental "# injection has been studied in this respect. "t appears that reducing the volume from +.5 m' to 4./ m' does not appreciably reduce success.C,+3 There have been no studies of potential differences in anesthetic success ith reduced anesthetic doses in primary "# injection. "# injection is advantageous in specific clinical situations, such as treatment of patients ith coagulopathy, in hom the risk and consequences of hematoma through nerve block anesthesia are significant> bilateral restorations> and treatment in hich residual soft% tissue anesthesia is especially undesirable.

"onsiderations
8ardiovascular effects associated ith "# injections, potential postoperative complications and relative contraindi cations merit comment. "ncreases in heart rate have been subjectively and objectively measured in appro9imately 3C0 of patients after "# injection of +5 Eg of epinephrine.2,.,/,+5,24 ?ean increases ere appro9imately 2C beats=minute, and heart rate returned to baseline ithin C minutes in over 5D0 of subjects.. "ncreases in heart rate are of little clinical significance in healthy patients. unless patients interpret them as emotionally or psychologically disturbing. "n this case, plain solutions !such as 10 mepivacaine ithout vasoconstrictor$ are acceptable alternatives, since no subjective increases in heart rate have been reported ith their use.D,. 7or similar reasons, it may be prudent to use solutions ithout vasoconstrictor for any patient ith cardiovascular disease for hom the proposed procedure is appropriately brief. 6eported postoperative complications include perceived hyperocclusion !.0$2,.,+5 and infection at the site of perforation !10$.2,+5 "f the patient has narro attached gingiva at the proposed site of "# injection or has severe periodontal disease, "# injection is contraindicated.+5,24

8omputer%8ontrolled Systems for the Delivery of 'ocal Anesthetic

The Band !?ilestone Scientific, 'ivingston, ,A$ is a computer%controlled pump modelled after those used in intravenous administration of general anesthetics !Table #> Fig. #$. "t can deliver a constant volume of anesthetic at constant pressure, hich purportedly enables less painful delivery of the anesthetic. This claim is based upon the premise that pain due to local anesthetic injection is attributable to factors such as fluid pressure on injection and flo rate. #ther purported advantages include greater tactile sensitivity and less intrusive appearance. 6elative disadvantages are higher cost and speed of injection F at the slo est pump rate, a total of C minutes is required to completely e9press a cartridge. "n a blinded, controlled trial, Asarch and others2+ sho ed no difference in pain ratings, pain behaviour or overall satisfaction ith dental treatment in pediatric patients receiving infiltration, "A,- and palatal injections ith the Band and a conventional syringe technique. There are fe if any other unbiased blinded, controlled trials upon hich to base any conclusions regarding the benefits of computer%controlled delivery systems. T o other computer%controlled delivery systems have been recently released< the 8omfort 8ontrol Syringe !?id est%Dentsply, Des &laines, "'$ and the )uicksleeper !Dental :itech, G" 8hamp -lanc, 7rance$.

&eriodontal 'igament "njection

&D' injection is also kno n as intraligamentary injection, transligamentary anesthesia and intraperiodontal anesthesia. #riginally described in +/2C, its application has since been the impetus for the design of speciali(ed syringes, including the ,%Tralig !?ilte9 "nstrument 8ompany, "nc. -ethpage$ !Table #> Fig. $$, the 'igamaject !:ealthco "nc., -oston, ?A$, and the &eripress !Hniversal Dental "mplements, *dison, ,A$. The term &D' injection is something of a misnomer. Bith this technique, anesthetic fluid spreads primarily along the outer surface of the alveolar plate and under the periosteum, moving into crestal marro spaces along vascular channels and not through the &D' as previously assumed.22 Therefore, hat is termed &D' injection should be considered a form of "# injection.22 The technique involves use of a 2D% or 23%gauge short needle or a 14%gauge ultrashort needle.+D *mpirical evidence suggests that longer, smaller%gauge needles are more apt to buckle on insertion> ho ever, &D' injection has been performed successfully ith all needle lengths and gauges in both standard syringes and speciali(ed pressure syringes !Fig. $$.+D The most objective measure of success F the onset, duration and rating of pain associated ith primary &D' injection F is response to *&T ! here success is defined as no response to ma9imal *&T output$.21,2C The follo ing discussion applies to mesial and distal injections !4.2 m' of 20 lidocaine and +<+44,444 epinephrine for each injection$ ith a 'igamaject syringe. #nset of anesthesia is rapid, if not immediate ! ithin 2 minutes of completion of the injection$.21 7or a primary &D' injection, the success rate at 2 minutes as 3/0 in mandibular and 3D0 in ma9illary first molars.21 :o ever, the success rate at 2 minutes as only +50 in mandibular and 1/0 in ma9illary lateral incisors.21 "n addition, success rates declined ith use of plain solutions.2C Bhen &D' injection as used as a supplement to conventional "A,-, the success rate as 350 for first molars. This improvement as maintained for appro9imately 24 minutes, after hich success as similar to that observed ith "A,- alone !.10$.3 Duration of anesthesia is brief for the primary &D' injection !combination of 4.2 m' for the mesial injection and 4.2 m' for the distal injection$, ith only 240 of mandibular and 2D0 of ma9illary first molars anestheti(ed +4 minutes after injection, and only +40 of mandibular and 140 of ma9illary later incisors anestheti(ed at this time point.21 "t is not clear hether use of 4.D0 bupivacaine significantly prolongs the duration of anesthesia ith primary &D' injection.2D Bithout topical anesthetic, insertion of the needle itself is rated as mildly to moderately painful and generally contributes to most of the perceived discomfort.21 ,eedle insertion is more painful in &D' injection for anesthesia of the ma9illary lateral incisor than for other teeth.21

The ability of &D' injection to produce anesthesia of a single tooth is unpredictable, and therefore its use as an aid in endodontic diagnosis is questionable.2.

"onsiderations
8ardiovascular effects, postoperative sequelae, and potential damage to pulp and periodontal structures merit discussion. The distribution of injected solutions is primarily intraosseous and perivascular, and rapid systemic absorption is likely. 23 8ardiovascular effects such as changes in mean arterial pressure and heart rate ere similar for &D', "# and intravenous injections of 1 Eg of epinephrine in dogs !4.1 m' lidocaine +<+44,444$.23 &ostoperative sequelae are common but self%limiting.21,2C &ain of mild or moderate severity as reported by 510 of patients after 2C hours.21 :yperocclusion as reported by 1.0 of patients after 2C hours and by 30 after 1 days.21 S ollen interdental papillae ere reported by +10 of patients.21 Damage to the crestal bone and cementum from needle trauma is possible, but is minor and reversible.25 *pithelial and connective tissue attachment to enamel are not disturbed by needle puncture.2/ "njection of the solution is not damaging. &ulpal changes after &D' injections are mild and reversible.14

,eedleless Aet%"njection Syringe Systems

7irst described in +5.., jet%injection devices ere originally developed for mass immuni(ation. ?odern designs have been approved for intramuscular and subcutaneous delivery of medications such as hepatitis - vaccine and insulin.1+ ,eedleless jet injectors such as the Syrijet ?ark "" system !?i((y "nc., 8herry :ill, ,A$ are marketed for use in the dental setting !Table #& Figs. %a ,%b, %c$. Acceptance of this needleless instrument is high among adult !/40$12 and pediatric !3D0$ populations.11 Situations in hich this system might be appropriate include placement of rubber dam clamps, placement of retraction cords, creation of drainage incisions for abscesses, and placement of orthodontic bands or space maintainers. 8ontrolled studies evaluating efficacy are lacking, and reports are primarily anecdotal. Soft%tissue anesthesia, determined by probing unattached gingiva, as reported as Igood.J1C The success rate for pulpal anesthesia of permanent ma9illary lateral incisors as poor !+10$, as assessed by pulp tests1C> ho ever, Saravia and -ush11 reported that anesthesia during ++ e9tractions of deciduous teeth and 2 pulpotomies as completely successful in a group of children averaging +4 years of age. Adverse effects are rare. There has been one report of clinically significant hematoma formation after jet injection ith the Syrijet.1D

The advantages of needleless systems for delivery of local anesthetic include rapid onset of anesthesia, predictable topical anesthesia of soft tissues, controlled delivery of anesthetic dose, obviation of needle%stick injury, obviation of intravascular injection and high patient acceptance, especially in instances of needle%phobia. The disadvantages are cost, the potential to frighten patients ith the sudden noise and pressure sensation that occur on delivery of the anesthetic, the intrusive appearance of the device, the possibility of small residual hematomas, leakage of anesthetic and questionable efficacy for pulpal anesthesia.

8onclusion
"# injection provides profound anesthesia for .4 minutes hen used as a supplement to failed "A,-. This is an appropriate alternative primary technique for procedures of short duration !less than 24 minutes$ and in situations in hich residual soft%tissue anesthesia is undesirable or nerve block carries a significant risk of hematoma. An increase in heart rate comparable to that e9perienced ith mild e9ercise should be anticipated and is of little consequence in healthy patients. 8omputer%controlled delivery systems have not been demonstrated conclusively to afford less painful delivery of local anesthesia relative to conventional syringes. &D' injection may be performed equally ell ith conventional syringes and pressure syringes. Bhen used as a primary technique, both methods are just as effective as conventional "A,- in achieving pulpal anesthesia, but the duration of action is much shorter. &D' injections are most effective in supplementing failed "A,-. &ostoperative sequelae such as soreness at injection sites are common but transient. Aet%injection systems appear to represent an effective alternative means to achieve topical anesthesia of oral mucous membranes. Their use in effecting pulpal anesthesia is questionable. 6elative dra backs include a potentially startling discharge of compressed gas. The primary advantages include obviation of needle%stick injuries and much better patient acceptance than for needle delivery. "n conclusion, kno ledge of adjunctive anesthetic techniques may broaden the dentistKs ability to provide appropriate local anesthesia. "t is important to critically evaluate any ne method to determine its merit. Techniques ith proven value may provide a beneficial supplement to traditional means of achieving local anesthesia.

Acknowledgments: The material in this manuscript was presented in part at the ,niversity of Toronto-s faculty of dentistry clinical conference series on anesthesia in !anuary $%%%. The author than.s #rs. /hawn !acobs and #aniel 0aas for assistance in preparation of this manuscript. Dr. Wong is a senior resident in the graduate anesthesia program, faculty of dentistry, ,niversity of Toronto.

Correspondence to: #r. !ason 1. 2ong, &&&-34%% 5eslie /t., Toronto, 67 8$! $1+. The author has no declared financial interest in any company manufacturing the types of products mentioned in this article.

6eferences
+. 8ertosimo AA, Archer 6D. A clinical evaluation of the electric pulp tester as an indicator of local anesthesia. 6per #ent +//.> 2+!+$<2D%14. 2. Dunbar D, 6eader A, ,ist 6, -eck ?, ?eyers BA. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. ! 9ndod +//.> 22!/$<C5+%.. 1. 8lark S, 6eader A, -eck ?, ?eyers BA. Anesthetic efficacy of the mylohyoid nerve block and combination inferior alveolar nerve block=mylohyoid nerve block. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod +///> 53!D$<DD3%.1. C. 6eit( A, 6eader A, ,ist 6, -eck ?, ?eyers BA. Anesthetic efficacy of the intraosseous injection of 4./ m' of 20 lidocaine !+<+44,444 epinephrine$ to augment an inferior alveolar nerve block. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod +//5> 5.!D$<D+.%21. D. ;allatin *, Stabile &, 6eader A, ,ist 6, -eck ?. Anesthetic efficacy and heart rate effects of the intraosseous injection of 10 mepivacaine after an inferior alveolar nerve block. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod 2444> 5/!+$<51%3. .. ;uglielmo A, 6eader A, ,ist 6, -eck ?, Beaver A. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 20 mepivacaine ith +<24,444 levonordefrin. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod +///> 53!1$<25C%/1. 3. 8hilders ?, 6eader A, ,ist 6, -eck ?, ?eyers BA. Anesthetic efficacy of the periodontal ligament injection after an inferior alveolar nerve block. ! 9ndod +//.> 22!.$<1+3%24. 5. 6eisman D, 6eader A, ,ist 6, -eck ?, Beaver A. Anesthetic efficacy of the supplemental intraosseous injection of 10 mepivacaine in irreversible pulpitis. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod +//3> 5C!.$<.3.%52. /. ,usstein A, 6eader A, ,ist 6, -eck ?, ?eyers BA. Anesthetic efficacy of the supplemental intraosseous injection of 20 lidocaine ith +<+44,444 epinephrine in irreversible pulpitis. ! 9ndod. +//5> 2C!3$<C53%/+. +4. Aeske A:, -oshart -7. Deflection of conventional versus nondeflecting dental needles in vitro. Anesth :rog +/5D> 12!2$<.2%C.

++. :annan ', 6eader A, ,ist 6, -eck ?, ?eyers BA. The use of ultrasound for guiding needle placement for inferior alveolar nerve blocks. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod +///> 53!.$<.D5%.D. +2. 6ood A&. Some anatomical and physiological causes of failure to achieve mandibular analgesia. <r ! 6ral /urg +/33> +D!+$<3D%52. +1. &arente SA, Anderson 6B, :erman BB, Limbrough B7, Beller 6,. Anesthetic efficacy of the supplemental intraosseous injection for teeth ith irreversible pulpitis. ! 9ndod +//5> 2C!+2$<52.%5. +C. 7riedman ?A, :ochman ?,. The A?SA injection< a ne concept for local anesthesia of ma9illary teeth using a computer%controlled injection system. =uintessence >nt +//5> 2/!D$<2/3%141. +D. Balton 6*, Abbott -A. &eriodontal ligament injection< a clinical evaluation. ! Am #ent Assoc +/5+> +41!C$<D3+%D. +.. -ennett 86, ?undell 6D, ?onheim '?. Studies on tissue penetration characteristics produced by jet injection. ! Am #ent Assoc +/3+> 51!1$<.2D%/. +3. 6eit( A, 6eader A, ,ist 6, -eck ?, ?eyers BA. Anesthetic efficacy of a repeated intraosseous injection given 14 min follo ing an inferior alveolar nerve block=intraosseous injection. Anesth :rog. +//5> CD!C$<+C1%/. +5. 8oggins 6, 6eader A, ,ist 6, -eck ?, ?eyers BA. Anesthetic efficacy of the intraosseous injection in ma9illary and mandibular teeth. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod +//.> 5+!.$<.1C%C+. +/. 6eplogle L, 6eader A, ,ist 6, -eck ?, Beaver A, ?eyers BA. Anesthetic efficacy of the intraosseous injection of 20 lidocaine !+<+44,444 epinephrine$ and 10 mepivacaine in mandibular first molars. 6ral /urg 6ral 8ed 6ral :athol 6ral ;adiol 9ndod +//3> 51!+$<14%3. 24. 6eplogle L, 6eader A, ,ist 6, -eck ?, Beaver A, ?eyers BA. 8ardiovascular effects of intraosseous injections of 2 percent lidocaine ith +<+44,444 epinephrine and 1 percent mepivacaine Msee commentsN. ! Am #ent Assoc +///> +14!D$<.C/%D3. 2+. Asarch T, Allen L, &etersen -, -eiraghi S. *fficacy of a computeri(ed local anesthesia device in pediatric dentistry. :ediatr #ent +///> 2+!3$<C2+%C. 22. Tagger ?, Tagger *, Sarnat :. &eriodontal ligament injection< spread of the solution in the dog. ! 9ndod +//C> 24!.$<251%3.

21. Bhite AA, 6eader A, -eck ?, ?eyers BA. The periodontal ligament injection< a comparison of the efficacy in human ma9illary and mandibular teeth. ! 9ndod +/55> +C!+4$<D45%+C. 2C. Schleder A6, 6eader A, -eck ?, ?eyers BA. The periodontal ligament injection< a comparison of 20 lidocaine, 10 mepivacaine, and +<+44,444 epinephrine to 20 lidocaine ith +<+44,444 epinephrine in human mandibular premolars. ! 9ndod +/55> +C!5$<1/3%C4C. 2D. ?c'ean ?*, Bayman -*, ?ayhe 6-. Duration of anesthesia using the periodontal ligament injection< a comparison of bupivacaine to lidocaine. Anesth :ain "ontrol #ent +//2> C!+$<243%+1. 2.. DKSou(a A*, Balton 6*, &eterson '8. &eriodontal ligament injection< an evaluation of the e9tent of anesthesia and postinjection discomfort. ! Am #ent Assoc +/53> ++C!1$<1C+%C. 23. Smith ;,, Balton 6*. &eriodontal ligament injection< distribution of injected solutions. 6ral /urg 6ral 8ed 6ral :athol +/51> DD!1$<212%5. 25. Balton 6*. Distribution of solutions ith the periodontal ligament injection< clinical, anatomical, and histological evidence. ! 9ndod +/5.> +2!+4$<C/2%D44. 2/. Balton 6*, ;arnick AA. The periodontal ligament injection< histologic effects on the periodontium in monkeys. ! 9ndod +/52> 5!+$<22%.. 14. Torabinejad ?, &eters D', &eckham ,, 6entchler '6, 6ichardson A. *lectron microscopic changes in human pulps after intraligamental injection. 6ral /urg 6ral 8ed 6ral :athol +//1> 3.!2$<2+/%2C. 1+. 'indmayer ", ?enassa L, 'ambert A, ?oghrabi A, 'egendre ', 'egault 8, and others. Development of ne jet injector for insulin therapy. #iabetes "are. +/5.> /!1$<2/C%3. 12. -ennett 86, ?onheim '?. &roduction of local anesthesia by jet injection. A clinical study. 6ral /urg 6ral 8ed 6ral :athol +/3+> 12!C$<D2.%14. 11. Saravia ?*, -ush A&. The needleless syringe< efficacy of anesthesia and patient preference in child dental patients. !ournal of "linical :ediatr #ent +//+> +D!2$<+4/%+2. 1C. 'ehtinen 6. *fficiency of jet injection technique in production of local anesthesia. :roc ?inn #ent /oc +/3/> 3D!+%2$<+1%C. 1D. Tabita &O. Side effect of the jet injector for the production of local anesthesia. Anesth :rog. +/3/> 2.!C$<+42%C.

8DA 6esource 8entre

To order the 6esource 8entreKs information package titled Anesthesia Hpdate, please contact us at tel.< +%544%2.3%.1DC or !.+1$ D21%+334, e9t. 2221> fa9< !.+1$ D21%.D3C> e% mail< infoPcda%adc.ca . The information package is available to members for Q+4.