Periodontai ligament anesthesia - A clinical

evaluation
Eriksen HM, Aamdal H, Kerekes K. PeriodonLal ligamenL anes-
thesia. A clinical evaluaLion. Endod Dent TraumaLoI 1986; 2:
267-269.
AbsLract ~ PeriodonLal ligamenL (PDL) injecLion was used either
as an alternative or as a supplement Lo conventional anesLhesia
techniques (CA) in connecLion with endodontic irealment of 339
teeth. Adequate analgesia was obtained more irequenLly wiLh CA
than wiLh PDL. However, total lack of effecL was registered only
in a few cases for boLh Lechniques. PDE was found Lo be of
parLicular value in Lhe mandibular posLerior segmenLs where
convenLional Lechniques mosL frequenLly failed.
Harald M. Erihsen, Hilde Aamdal and
Kasmer Kerekes
Oepartmenf of Operative Dentistry and Endodon-
tics, Dental Factilty, University of Oslo, Oslo,
Norway
Key words: denfal anesthesia, periodonfal ligament.
Harald M. Eriksen, Odontologiklinikkene, P.O.Box
1109 Blindern, 0317 Oslo 3, Norway.
Accepted for publication 28 April 1986.

Pain control during dental treatment is generally Material and methods

achieved by local anesthesia. Local infiUraLion and
local block anesthesia are ihe mosL commonly used
meLhods. Local infiltration is usually sufficient in
maxilla and the mandibular anLerior regions while
mandibular block anesLhesia is regularly applied for
Lhe posLerior mandibular segmenLs.
However, conventional methods may have some
untoward side-effects. Unnecessary soft tissue anal-
gesia may lead to biLe wounds in children and men-
tally retarded persons. Accidental damage to nerve
trunks or blood vessels may occur resulting in par-
esthesia or hematoma. In addition, fairly large doses
mighL be applied in order to obLain suOicient anal-
gesia of the desired region.
Periodontai ligamenl injection has been intro-
duced in order to reduce the side-effects linked to
convenLional Lechniques. Thin (30 gauge) needles
are inserted into the gingival crevice towards the
peridontal ligamenL. The anesLhelic solution is in-
jected with pressure in order Lo obtain diffusion
around the root. Several investigations conclude la-
vorably for periodonlal ligament anesLhesia (1-7)
and hisLologic invesLigaLions have shown minor Lis-
sue damage (1,8-10). FurLhermore, Lhe advantage
of seleclive anesthesia as a diagnostic Lool is empha-
sized (5, 11). However, pulpal ischemia has been
reported (12). This may render the pulp vulnerable
to damage of iatrogenic origin.
The purpose of ihe present investigation was Lo
evaluate the effecLiveness of periodonLal ligamenL
anesthesia when used by supervised denLal students.
The method was evaluated either as an aherna-
tive or as a supplement to conventional techniques
in connection with endodonLic LreatmenL.
The invesLigaLion included 339 teeth in paLients
referred for endodonLic treaLment at the Depart-
ment of Endodontics, DenLal Faeulty, Universily of
Oslo. All tooth groups were represented and the
LeeLh had fully developed rools and viLal pulps.
Periodontai ligamenL injecLion was arbiLrarily
chosen in 135 cases and conventional anesthesia
techniques in 127 cases. In addition, periodonLal
ligamenL injection was used as a supplement in 88
cases during a prolonged investigation period when
adequate responses were not obLained by conven-
Lional techniques. The responses were classified as -
adequaLe: pulpeetomy could be performed without
pain; partial: pulpecLomy could be performed with
Lolerable discomforL; unacceptable: pulpeetomy
could not be performed due Lo intolerable pain.
Ligmaject was used for Lhe periodontai ligament
injection. Xylocaine 2Omg7ml with Adrenaline 1:
50 000 was used routinely. In a few cases where
vasoconstrictor was conLraindicated, Carbocaine
dental 30mg/ml was applied. A quesLionnaire eval-
uaLing Lhe aLLiLude of both operaLors and patients
Lowards periodontai ligament injection was also in-
cluded in the invesdgation.
Results
The overall results are given in Table 1. AdequaLe
response was obtained in 78% of Lhe 127 teelh
anesthetized wilh conventional techniques while an
adequate response was obtained in only 61% of the
135 teeth treated with periodonfal ligament injec-
tion. This difference was found to be statistically

267
Eriksen et al.
Table 1. The results of periodonfal Iigamenf (POL) injection compared wifh pain after periodontai ligament injection was re-
convenfional anesthesia fechniques (CA) and POL used as a supplemenf
when CA failed (CA + POL). The responses fo CA + PDL was regisfered
ported in a few cases.
over a prolonged period. The difference befween PDL and CA was sfafisfically
significanf (0.01 < p < 0 . 0 2 for )c^=9.05) using chi-square fesf.
Results of anesfhesia, all foofh groups included
Discussien

Adequafe Partial Unaccepfable

POL 135 82 (61%) 47 (35%)
CA 127 99 (78%) 25 (20%)
CA + POL 88 49 (56%) 28 (32%)
significanL (p<0.02, chi-square tesl). However,
when including Lhe parLial responses, Lhere was no
diflerence belween the lwo anesthesia techniques.
Only a few unacceptable re.sponses were observed.
Periodontai ligament injection was also used as a
supplemenL in 88 cases where convenLional anes-
thesia techniques failed. This was done during a
prolonged period and Lhe results (Table 1) show
LhaL adequaLe or parLial responses were oblained in
88% of the eases treated. A slaLisLical evaluaLion of
Lhis approach eompared wilh lhe lwo techniques
applied alone is irrelevant because Lhis combined
technique was LesLed on selecLed cases over a pro-
longed period. Mandibular block anesLhesia ap-
peared Lo be the conventional technique demon-
strating the highest frequency of failures in our sLu-
denL clinic. The resuhs obLained for Lhe posLerior
mandibular regions by lhe three differenL pro-
cedures LesLed are Lherefore considered of parLicular
inLeresL and are presenLed in Table 2.
The resuhs demonsLraled lhat periodonLal liga-
ment injection and the convenLional mandibular
block anesthesia techniques were equally successful
in this region. FurLhermore, adequaLe response Lo
periodontai ligament injecLion was obLained in 577o
and partial response in anoLher 36% of 42 cases
where the conventional mandibular block anes-
Lhesia Leehnique failed iniLially.
Based on the results from the quesLionnaire a
majoriLy of operaLors (90%,) and padenLs (70%)
were in favor of periodontai ligament injecLion com-
pared with convenlional lechniques. PostoperaLive
Table 2. The response fo various anesfhesia fechniques in fhe mandibular
posferior segmenfs; periodontai Iigamenf (POL) injecfion, convenfional anes-
thesia technique (CA) and periodonfal Iigamenf injecfion used as a supplemenf
where convenfional mandibular block technique failed (OA + POL). The
responses fo CA -i- PDL was registered over a prolonged period.
Results of anesfhesia, posferior mandibular regions
Adequafe Parfial
PDL 41 29 (71%) 11 (27%)
CA 35 24 (69%) 10 (28%)
CA PDL 42 24 (57%) 15 (36%)
It is mandalory boLh for Lhe paLient and the oper-
ator to have acceptable tmalgcsia during pulpeeto-
6 (4%) my. A higher frequency of adequate responses lo
3 (2%) conventional techniques than to the periodonLal
11 (12%)
ligamenL injection was found in Lhe present investi-
gation. This indicaled that, properly administered,
the conventional techniques were more reliable than
the periodontai ligament procedure. However, if
partial anesLhesia with minor discomfort was con-
sidered acceptable, no difference beLween Lhe Lwo
Lechniciues seemed Lo exisL. The overall success-raLe
of 6 1 % for PDL anesLhesia (Table 1) and 69%
when considering posLerior mandibular regions ex-
clusively (Table 2) confirmed Lhe results reporLed
by Malamed (6). The observed success-raLes for
convenLional techniques were also in good agree-
ment with generally accepLed figures (13).
Furthermore, lhe periodonLal ligamenL injecLion
mighL have cerlain advantages in the posLerior man-
dibular region (Table 2). The invesLigation demon-
sLraLed LhaL periodontai ligamenL injecLion migliL be
a valuable supplemenL if convenLional Lechniques
fail. Periodontai ligamenL injeeLion was well ac-
cepLed by a majoriLy of boLh operaLors and paLienLs.
The duraLion of Lhe periodonLal ligament injection
is reporLed Lo be equal to conventional anesthesia
Lechniques (6).
These observations left us with the periodontai
ligament Lechnicjue as a valuable allernative for
minor operaLive procedures requiring local anal-
gesia. Unnecessary soft tissue analgesia was mini-
mized and normal funcLions were noL impaired (14).
FurLhermore, Lhe risks of hematoma and parelhesia
due to unintended nerve damage are avoided. Re-
duced amounls of anesthetic solution may be sup-
plied (1, 3, 10). However, the periodonLal ligamenL
technique is reported to produce extensive pulpal
ischemia (12). This effecL may in parL be responsible
for Lhe anesthesia iLself and, conceivably, the pulpal
tolerance may be reduced. Precautions should
Lherefore be Laken when periodonLal ligamenL injec-
Lion is used for operative procedures on vital leeth
(15).
In the present investigation, level of sensitivity Lo
pulpeetomy was used as the parameter. Individual
pain thresholds and tolerance may vary and lhe
results should therefore be considered as a subjec-
Unaccepfable tive, but clinically relevant, evaluaLion of local anes-
Lhesia techniques.
1 (2%) A few patienLs reporLed posLo]3erative discomforL,
1 (3%)
3 (7%)
mainly Lenderness Lo percussion and chewing after
periodontai ligamenL injecLion (1, 3, 6). This may

268

have been due Lo local, reversible damage lo peri-
odontai sLructures (1, 7, 10).
The high injecLion pressui-e caused fracLurc of
a few anesthesia carpuies. The syringes specially
designed tor jiieriodontal ligament injection have a
shield around the carpuies preventing Lhe e\'entual
spread of glass fragments in the oral cavity. Such
shields are mandatory for proper use of lhe peri-
odontai ligament injeclion technique.
Cenclusions
Periodontai ligamenl injection was found to be a
fairly efficient and convenient method, even in the
mandibular molar regions, but the success-rate was
lower than for conventional lechniques. The pro-
cedure was well accepted by lhe patients. The dura-
bility of the analgesia obtained was found to be
comparable to conventional techniques with less
anestheLic soluLion applied. Slight postoperative
pain occurred infrequently. The method was con-
sidered a valuable supplemenL lo conventional lech-
niques.
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269