A Comparison of Periodontal Intraligamental Anesthesia

Using Etidocaine HCI and Lidocaine HCI

Georgia K. Johnson, D.D.S., M.S.,* Gwen L. Hiava, R.D.H., M.S.,t
Kenneth L. Kalkwarf, D.D.S., M.S.*
Departments of *Periodontics and tDental Hygiene, University of Nebraska Medical Center College of
Dentistry, Lincoln, Nebraska

Summary
A double-blind method was used to compare anesthesia duration following intraligamental administra-
tion of 1.5% etidocaine with 1:200,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine.
Durations of anesthesia in pulpal and soft tissues were monitored following periodontal ligament
injections adjacent to the maxillary canines of 20 individuals. Complete pulpal anesthesia was attained
in 35% of the teeth injected with etidocaine and in 55% of those receiving lidocaine. Soft tissue
anesthesia was consistently achieved. Both pulpal and soft tissue anesthesia were of longer duration
following the use of lidocaine solution. These findings suggest that anesthetic duration following
periodontal ligament injections is more related to the concentration of vasoconstrictor than to the
anesthetic solution employed.

Introduction of the periodontal ligament injection include the pos-

The periodontal ligament injection using a conven-
tional syringe has traditionally been used as a sup-
plement to regional or infiltration anesthesia. In-
traligamental injections have become more popular
since the 1970s due to the introduction of pressure-
type syringes specifically designed for periodontal
ligament (PDL) injections. Using these mechanical
delivery devices, intraligamental anesthesia has
been suggested as an alternative to more conven-
tional injection techniques.1'2
The primary advantages of the new syringes in-
clude a sleeve over the anesthetic cartridge affording
protection should the cartridge shatter during injec-
tion pressure and the ability to generate the neces-
sary pressure with greater ease than with conven-
tional syringes. These injection devices use a short
30 gauge needle to engage the entrance into the
periodontal ligament space interproximally and facili-
tate the deposition of a small amount (0.2 ml) of
anesthetic solution under pressure.1'2
The amount of anesthetic solution used is less than
in conventional injections and there is little chance of
intravascular injection.' Other reported advantages
This study was supported by a grant from the UNMC College of
Dentistry.
Accepted for publication August 7, 1985.
Address all correspondence to, Dr. Georgia Johnson, UNMC
College of Dentistry, 40th and Holdrege, Department of Periodon-
tics, Lincoln, Nebraska 68583-0740.
202
sibility of limiting anesthesia to a single tooth and
avoiding numbness to the lip and tongue.1'3 Profound
anesthesia lasting 45-55 minutes has been re-
ported.3 Disadvantages of the technique, including
the need for a special armamentarium, focal tissue
damage produced by excessive pressure, and post-
injection discomfort have been discussed.34 It has
been reported that the technique requires practice
and may not be 100% effective.4 Clinical studies of
the PDL injection used as an alternative or adjunctive
method have reported an effectiveness ranging from
63-92% with both conventional and pressure type
syringes.2' 5-8 The existing clinical research indicates
a wide variation in the duration of pulpal anesthesia
ranging from 1 to 27 minutes.9 The length of soft
tissue anesthesia obtained has not been extensively
examined.
Another advance in the area of local anesthesia in
dentistry has been the introduction of the long-acting
local anesthetics, etidocaine being the most recent of
these. Etidocaine is chemically and pharmacologi-
cally related to lidocaine, although it is more firmly
bound to nerve membranes and possesses a greater
degree of lipid solubility.1 0 Thus, it is able to retain the
rapid onset quality of lidocaine while significantly pro-
longing the duration of anesthesia.-1
The purpose of this investigation was to compare
the duration of pulpal and soft tissue anesthesia ob-
tained with 1.5% etidocaine with 1:200,000 epineph-
rine (Duranest HCI, Astra Pharmaceutical Products
Inc., Worcester, MA.) to that of 2% lidocaine with
ANESTHESIA PROGRESS
1:100,000 epinephrine (Xylocaine HCI, Astra Phar-
maceutical Products, Inc.) using intraligamentary in-
jection on the maxillary canines in humans.
Methods
Twenty individuals (dental faculty, staff, or stu-
dents) were recruited to participate in this study. All
subjects (1) were in good general health; (2) were
free of allergy to the amide group of local anesthetic
agents; (3) had maxillary canines free of detectable
caries activity or restorations and; (4) had clinically
healthy gingiva. The participants signed an informed
consent form approved by the Institutional Review
Board for the protection of human subjects.
Intraligamental anesthesia using a pressure-type
syringe (Ligmaject, Healthco Dental Supply, Boston,
MA) was administered to the patients' maxillary
canines employing a double-blind method. One
canine, chosen randomly, received 2% lidocaine with
1:100,000 epinephrine and the contralateral cuspid
received 1.5% etidocaine with 1:200,000 epineph-
rine. The left maxillary central incisor served as a
control and received no injection.
The recommended injection technique for the
special periodontal ligament injection device was
used: an extra short 30 gauge needle was inserted
into the gingival sulcus at a 300 angle to the distal
proximal aspect of the tooth. With the bevel facing
away from the tooth and the needle wedged between
the alveolar bone and tooth, one trigger pull of solu-
tion (0.2 ml) was slowly administered.8 This pro-
cedure was repeated on the mesial proximal aspect
of the tooth. An attempt was made to position the
needle so that a back pressure was felt during the
injection procedure.8
Pulpal and soft tissue anesthesia were assessed.
A digital pulp tester (Analytical Technology Vitality
Scanner, Analytic Technology, Redmond, WA) with a
0-80 unit range of possible responses was used to
test the sensitivity of the teeth prior to injection
(baseline level). The patient was told to acknowledge
the first awareness of sensation. Following the injec-
tions, the experimental and control teeth were pulp
tested again. If, after the first injections, the patient
felt sensation before reaching the maximum level on
TABLE 1 Mean Duration of Pulpal and Soft Tissue Anesthesia
Pulpal anesthesia
mean-+SEM
1.5% Etidocaine with 1:200,000 epinephrine
2% Lidocaine with 1:100,000 epinephrine
aValues significantly different from corresponding lidocaine values (p<.05).
bValues significantly different from corresponding lidocaine values (p<.01).
SEPTEMBER/OCTOBER 1985
the vitalometer, the injections were repeated. Electric
pulp testing was repeated at two-minute intervals
until the pulp tester reading was within 20% of
baseline, and the same reading was obtained at three
consecutive intervals. If the pain threshold did not
initially rise 20% above baseline following two
episodes of injections, the trial was termed an
anesthetic failure, and only soft tissue anesthesia
was assessed.
Soft tissue anesthesia was defined as the inability
to detect a sharp sensation when the facial gingival
tissue at the mesial and distal papillary regions was
pricked with a dental explorer. This was evaluated at
two minute intervals until sensation returned.
A paired t-test was used to compare the duration of
pulpal and soft tissue anesthesia obtained with the
two agents.
Results
Approximately the same mean number of injec-
tions was given per patient with 1.5% etidocaine as
with 2% lidocaine (3.7+0.2 and 3.6+ 0.2). The dura-
tion of pulpal anesthesia (Table 1), 9.8+2.9 minutes
for the etidocaine and 17.3+4.5 minutes for the
lidocaine solution, was significantly different (p<.05).
Etidocaine achieved profound pulpal anesthesia (no
response at 80 on the vitalometer) in seven patients.
Lidocaine obatined profound pulpal anesthesia in 11
patients. Anesthesia failure was recorded in six
cases with etidocaine and five with lidocaine. In the
remainder of the patients, pulpal anesthesia at a level
20% greater than baseline was achieved (seven
cases for etidocaine and four cases for lidocaine).
Soft tissue anesthesia was obtained in all trials.
Soft tissue anesthesia following injection of
etidocaine lasted 27.0+-3.1 minutes at the distal
papilla and 26.5+-3.5 minutes at the mesial. Soft
tissue anesthesia with lidocaine was 39.74.8 min-
utes on the distal and 41.0+3.9 minutes on the me-
sial. The difference between the mean duration of
soft tissue anesthesia obtained with the two anesthe-
tic agents was statistically significant (p<.01) as
noted in Table 1. The duration of pulpal anesthesia
was significantly different from that of the soft tissue
anesthesia for both anesthetic agenits (p<.01).
Soft tissue anesthesia
(min) (min)
mean-+SEM
Distal Mesial
9.8+2.9a 27.0+3.1 b 26.5+3.5b
17.3+4.8 39.7+4.8 41.0+4.8
203
 Discussion
Kaufman and co-workers9 (1984) reported a rela-
tionship between duration of local anesthesia and
vasoconstrictor concentration. They found that 2%
lidocaine with 1:50,000 epinephrine produced pulpal
anesthesia which lasted 27.1 +22.2 min, whereas
0.5% bupivacaine with 1:200,000 epinephrine pro-
duced anesthesia for 3.7+4.9 min. The mean dura-
tion of pulpal anesthesia was 1.11.2 min when 2%
lidocaine without vasoconstrictor was used. Our re-
sults with 2% lidocaine with 1:100,000 epinephrine
demonstrated a duration of pulpal anesthesia of
17.34.8 min, a shorter duration than Kaufman's
group found with the same anesthetic with 1:200,000
epinephrine. Taken together, these data suggest that
the duration of local anesthesia may be influenced
more by the concentration of the vasoconstrictor
employed rather than the type of local anesthetic
agent employed (at equipotent concentrations).
Other studies have evaluated the clinical effective-
ness of intraligamental anesthesia both as an alter-
native or adjunct to conventional techniques.
Malamed2 found that the PDL injection, using a
pressure-type syringe, was successful in 88.5% of
cases involving oral surgical, periodontal, endodon-
tic, and restorative procedures, compared to an
82.1% success rate for infiltration and block anes-
thesia. Intraligamental anesthesia was effective in
81 % of 200 similar cases reported by Faulkner.6 Al-
though Kaufman and co-workers5 demonstrated an
overall clinical success rate of 84%, satisfactory re-
sults were attained in only 46% of the canines. This is
quite similar to the present study, where profound
pulpal anesthesia (no response at maximum on the
vitalometer) was achieved in 35% of the cases in-
jected with etidocaine and in 55% of the lidocaine-
injected cases. The maxillary canine has the longest
root in the dentitionl3 which may make intraligamen-
tal anesthesia more difficult to achieve.
The ADA Council on Dental Materials, Instru-
ments, and Equipment14 has recommended that in-
traligamental anesthesia should be reserved for use
as an adjunct to conventional techniques. Two inves-
tigations have demonstrated a 92% and 83% suc-
cess rate using the PDL injection in this manner.78
The ADA's recommendation that intraligamental
anesthesia be used only as a supplemental pro-
cedure is based on concern over the technique's
effect on the dental pulp and periodontal tissues and
the potential for postinjection complications.
The consensus of existing research on the histologic
effects of the PDL injection is that it is a relatively
inocuous procedure which may result in minor,
reversible damage to a healthy periodontium.1-17
There have been reports that intraligamental injec-
tion may lead to cemental resorption,1819 but Peter-
son18 stated that these areas were shallow and
showed evidence of repair. There is concern that
enamel hypoplasia of permanent molars may occur
204
when the technique is used on primary teeth with
developing permanent teeth in close approxima-
tion.20 At present there is no evidence that the injec-
tion is injurious to pulpal tissues.19
There have been clinical reports of soft tissue nec-
rosis and tooth tenderness following the PDL injec-
tion and one case of tooth avulsion.21 In the present
study, one patient experienced gingival sloughing
following lidocaine injections, and the majority of par-
ticipants related that the teeth involved in the study
were sensitive to biting pressures for 24-48 hours.
Manufacturers acknowledge that the possibility of
postoperative discomfort exists and suggest the use
of acetaminophin for relief.14
Recent studies using injection of dyes22'23 have
indicated that the intraligamental injection is actually
an intraosseous injection. Our clinical experience
supports this finding. Two subjects experienced pul-
pal anesthesia at least two teeth removed from the
injection site. Because earlier studies had shown that
intraosseous injection of anesthetic solutions con-
taining vasoconstrictors had an effect on pulse rate
and blood pressure in humans,24 Smith and
Pashley25 examined the systemic effects of epineph-
rine (1:100,000) in 0.3 ml of anesthetic solutions ad-
ministered via the PDL route in dogs. They found that
epinephrine administered via intraosseous, PDL, or
intravenous routes caused similar, rapid but transient
periods of hypotension and tachycardia which are
probably clinically significant. Based on these find-
ings, the authors recommended that cate-
cholamine-containing local anesthetic agents should
not be used for PDL injections in medically com-
promised patients. It is interesting that Khedari has
stated that ligamental injections reduce the risk to the
patient because they require the smallest amount of
solution.1
The consensus of the existing research suggests,
that when used with good clinical judgement, the PDL
injection is a relatively safe procedure. The most com-
monly encountered complication seem to be
postinjection tenderness of the periodontium. The
results of the present study indicate that intraliga-
mental anesthesia is not a totally predictable
technique, although the results may have been more
favorable if teeth other than maxillary canines were
used. Intraligamental anesthesia does not appear to
offer any significant advantages in the maxillary arch
over infiltration anesthesia. The use of epinephrine-
containing local anesthetic solutions for intraligamen-
tal injections is not recommended in medically com-
promised patients because of the intraosseous na-
ture of the injection and the resultant rapid uptake of
solution. The PDL injection may be useful in specific
situations, such as an adjunctive measure when con-
ventional techniques have failed to provide adequate
anesthesia or in cases of patient preference. How-
ever, this method does not represent a replacement
for the traditional techniques of infiltration and block
anesthesia.
ANESTHESIA PROGRESS
 References
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205