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Intraligamentary anesthesia:
Benefits and limitations
Tatsuo Endo, DDS, PhD1/Joachim Gabka, MD, DDS2/
Lothar Taubenheim3

Intraligamentary anesthesia was described in France early in the 20th century as a novel
and effective method of dental local anesthesia, but the method did not become estab-
lished because of the inadequacy of dental instruments available at the time. Today, the
use of a state-of-the-art armamentarium and the administration of well-proven anesthetic
agents with intraligamentary anesthesia reduce the experience of typical unwanted effects,
that is, sensation of elongation, pressure pain, precontact after the end of the analgesia,
and reversible tissue changes. Dosing lever and dosing wheel syringes in combination
with system-adapted injection needles enable the operator to feel the back-pressure and
inject the anesthetic smoothly into the periodontal ligament. The results of most recent
studies show that periodontal ligament injections do not generate unwanted effects when
sensible instruments are used, proven anesthetics are administered, and the anesthesia
method is practiced lege artis and mastered safely by the operator. This article discusses
the advantages and technique of intraligamentary anesthesia and presents results from
recent studies in the literature. (Quintessence Int 2007;37:88.e15–25)

Key words: dosing lever syringe, dosing wheel syringe, intraligamentary anesthesia,
periodontal ligament injection, pistol-type syringe, single-tooth anesthesia,
unwanted effects

Because of the increased life expectancy
and especially the diagnostic and therapeu-
tic techniques of modern medicine, more
and more high-risk patients visit dental prac-
titioners. Many who have had a bypass have
had a myocardial infarction or are receiving
1
Division of Operative Dentistry, Tohoku University Graduate
School of Dentistry, Sendai, Miyagi, Japan.
2
Deceased, formerly, Professor Emeritus, Berlin, Germany.
3
Med. Journalist, Erkrath, Germany.
Correspondence: Lothar Taubenheim, Am Thieleshof 24,
D-40699 Erkrath, Germany. E-mail: LT.Lothar.Taubenheim@
t-online.de
medical and drug treatment for elevated
blood pressure. Their general condition may
be considerably affected by the forms of
local anesthesia currently used in dentistry,
namely, infiltration and inferior alveolar nerve
block anesthesia. Intraligamentary anesthe-
sia (ILA), a third method of local anesthesia,
offers a gentle way of making the patient
insensitive to pain and has been increasingly
used during the past few years—unfortunate-
ly, though, not frequently enough. Through
the use of fine injection needles and the ap-
plication of small amounts of local anesthet-
ic solutions into the periodontal ligament, a
patient’s general condition is affected very lit-
tle, even if his or her cardiovascular function
is seriously impaired.

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The advantages of a pinpoint and very limit-
ed elimination of pain were always clear and
obvious; however, until the late 1970s, no
syringes could deliver such a small amount of
anesthetic solution precisely to the point and
with the necessary high pressure to overcome
the back-pressure of the periodontium.
Moreover, the injection needles required for this
purpose were not available then. This situation
has changed completely. The question arises
as to why the principle of ILA has not gained
equal ranking as a method of eliminating pain
for the dental patient, especially the high-risk
patient. Why do only few universities train stu-
dents in this gentle and patient-friendly form of
local dental anesthesia and provide possibili-
ties of its practical application?
With regard to its risk-benefit profile, ILA
has enormous advantages over the nerve
block, infiltration, and intraseptal anesthesia
methods, especially in patients of an
advanced age.
STATE OF THE ART
OF LOCAL DENTAL
ANESTHESIA
Nerve block anesthesia is taught as a
method of eliminating pain in the mandible
even though it involves a number of well-
known risks:
• The onset of anesthesia is delayed in the
presence of abnormal anatomic condi-
tions or if the technique is applied inade-
quately. An absolute failure of anesthesia
may occur in rare cases.
• The relatively high dosage of approxi-
mately 1.8 mL of anesthetic causes an
unnecessary strain on the patient’s car-
diovascular system, especially if the first
injection has not produced the desired
effect. (In patients with severe cardiovas-
cular disease, complications may also be
produced by ILA—in very rare cases—
when a dosage of just 0.6 mL is given.)
• The blockage of the entire trunk of the
mandibular nerve leads to an unpleasant
and undesired numbness of tongue, lips,
and cheeks.
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• Anesthesia usually lasts much longer than
is necessary.
• Although it happens only in very rare
cases, the mandibular nerve may be hit
when the injection needle is introduced
into the mandibular foramen, and this is
very painful. A direct puncture possibly in
association with injury to the lingual nerve
is even worse and may lead to a paresis
existing for many years.
Aspiration may provide effective protec-
tion against intravascular injection. However,
in patients with an hemorrhagic diathesis
and those treated with an anticoagulant, it
can cause soft tissue hematomas1 and is
therefore indicated only in exceptional cases.
In view of the relatively high number of risks
and side effects, the use of nerve block anes-
thesia must not only be precisely explained
but also be governed by strict indications.
Infiltration or terminal anesthesia, usually
applied to the maxilla and the entire anterior
region, produces a reservoir of anesthetic in
the operating area to desensitize the sensi-
tive nerve endings. The unwanted adverse
effects are comparable with those of inferior
alveolar nerve block anesthesia, except the
risk of hitting a nerve trunk.
Depending on the condition of the
patient’s cortex, labial buccal injection is sim-
ple and recommended if several teeth in 1
quadrant are to be treated. Palatal injection,
on the other hand, is very unpleasant and
often painful when the periosteum is hit.
If a single tooth is to be treated, ILA is the
only positive alternative. ILA may be applied
only if the clinician is capable of using this
technique. However, since the technique of
the periodontal ligament injection is relative-
ly easy to learn, the clinician will have only
minor problems in the beginning, if any.
These will mainly be technical difficulties
resulting from the use of inadequate instru-
ments or from locating the correct injection
site.
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Fig 1 Dosing lever syringe Citoject for pinpoint application of anesthetic agent. (1)
Headpiece, (6) handpiece, (2) viewing chamber of cartridge, (7) dosage lever, (3) burst guard,
(8) resetting key for dosing plunger, (4) bayonet catch, (9) dosing plunger, (5) threaded noz-
zle for injection needle, (10) injection needle.

Fig 2 Dosing wheel syringe SoftJect without force-increasing lever. (1) Barrel, (5) dosing
wheel, (2) viewing chamber for cartridge, (6) dosing plunger, (3) plastic sleeve of polytetra-
fluoroethylene (PTFE), (7) threaded nozzle for injection needle, (4) bayonet catch, (8) hand-
piece.

PREREQUISITES tions (Fig 1). This syringe allowed an exact

FOR INTRALIGAMENTAL
INJECTIONS
The success of ILA depends, above all, on
appropriate instruments. When Bourdin,
Granjeon, and Chompret2 introduced ILA as
a novel method of dental local anesthesia in
1925, the method did not become estab-
lished because of the inadequacy of dental
instruments available at the time. In the early
1980s, pressure syringes of the so-called pis-
tol type were promoted to overcome the
strong back-pressure when injecting into the
periodontal ligament. Because of extreme
operator variability and the potential for
postinjection complications, in 1983, Gio-
vannitti and Nique3 did not recommend this
technique for routine use. Injection systems
of the pistol type are now obsolete.
For years, the dosing lever syringe Citoject,
an injection system introduced to the mar-
ket by Bayer in 1984, was the standard
instrument for periodontal ligament injec-
dosage of very small amounts of local anes-
thetic by pinpoint application of several injec-
tions of 0.06 mL. It was said that the continu-
ous high pressure maintained during
injection determined the success of ILA.
In 1998, an armamentarium with a com-
pletely different dosing system—without a
lever—was conceived; a dosing wheel trans-
mitted the injection force applied by the oper-
ator on the plunger, thus enabling the operator
to feel the back-pressure of the tissue in the
thumb or finger and control the injection pres-
sure accordingly. This new dosing system was
called SoftJect (Henke-Sass, Wolf; Fig 2).
The selection of adequate injection nee-
dles is critical, too. The sulcus between tooth
and alveolar bone is extremely small; the
injection needle used for ILA must have an
external diameter no larger than 0.3 mm (=
30 G). The tip of the injection needle must
have an extra-short bevel to prevent it from
bending while in contact with the tooth,
which would increase resistance.

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Table 1 Failure rate of anesthesia methods7
Anesthesia No. of Failure Relative
method cases rate difference
Inferior alveolar
nerve block 202 20.8% (= 281.1%)
Terminal anesthesia 225 12.9% (= 174.3%)
Intraligamentary
anesthesia 202 7.4% (= 100%)
The current recommendation is to use
system-adapted injection needles, 0.3 mm (=
30 G) with a length between 12 and 16 mm,
adjusted to the injection system and with the
necessary stiffness to prevent bending dur-
ing insertion.
For intraligamental injections, the needle
must be introduced to a depth of 1 to 2 mm,
maximum 3 mm, into the periodontal liga-
ment. It should rest firmly in the sulcus and
remain fixed there during the injection
process. The injection time is about 20 sec-
onds for 0.2 mL, which means that the injec-
tion is very slow. Since about 0.2 mL of anes-
thetic agent per root is required, the injection
time is about 20 seconds for a one-rooted
tooth. Injection time should be longer for the
second root and more than 25 seconds for
the third root of a 3-rooted molar; this is to
prevent unwanted effects such as sensation
of elongation or precontact after return of
sensitivity.4 Anesthesia onset takes immedi-
ate effect after injection and reaches its full
impact in 30 seconds at the longest.
The range of anesthetics is not restricted;
all substances in common use may be
applied without restriction. The question Gray
et al5 posed: “Periodontal ligament injection:
with or without a vasoconstrictor?” has been
answered in favor of vasoconstrictor-contain-
ing anesthetic solutions.5 Because of the low
dosage required, even those solutions with a
relatively high addition of adrenaline may be
applied. As an anesthetic solution, the proven
substance articaine hydrochloride 4% with
adrenaline 1:200,000, eg, Ultracain DS
(Hoechst, now Sanofi-Aventis), introduced in
1975, may be used, as for all the aforemen-
tioned anesthesia methods.
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Under no circumstance should a local
anesthetic cartridge that has been used on
one patient ever be used to inject another.6
APPLICATION
The technique to achieve ILA is easy to learn.
Unlike nerve block anesthesia, the entire
process can be visually controlled. Thus, any
failure of anesthesia can be immediately
detected.
Injection needles to be used in ILA must
be very fine. To reach distal injection points
with minimal problems, the needle can be
angled in the direction needed. The cap of
the needle should be used for the angula-
tion. It is advisable to support the front part of
the syringe with one finger of the other hand
during injection to prevent bending of the
needle (Fig 3). Mesial and distal surfaces are
the sites of injection for molars, premolars,
and anterior teeth (Fig 4).
Unlike with infiltration anesthesia, the
patient hardly feels any pain during insertion
of the needle into the gingival sulcus. To pre-
vent even the minimal pain of needle inser-
tion, by using the dosing wheel syringe, it is
possible to apply 1 drop of anesthetic agent
on the place where the needle will be insert-
ed and thus desensitize the injection point.
As soon as the needle is fixed in the sul-
cus, the injection begins. A relatively high tis-
sue resistance (back-pressure) must be over-
come, and this is achieved by maintaining
the injection pressure. This injection pres-
sure is created by pressing the thumb or
index finger smoothly onto the dosage lever
(Citoject) or by turning the dosing wheel for-
ward (SoftJect), optimally by using the
thumb. Pressure is then transmitted to the
plunger, which empties the anesthetic-con-
taining cartridge. The applied pressure is to
be maintained throughout the injection
process to secure diffusion of the anesthetic
into the tissue (Fig 5). The onset of anesthe-
sia is normally accompanied by a change in
color of the marginal gingiva; as a result of
vasoconstriction, it turns a pinkish white.
After the injection of about 0.2 mL of anes-
thetic per root, within approximately 20 sec-
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Maxilla

Fig 3 (above) The front part of the syringe is sup-

ported with 1 finger of the other hand during injec-
tion to prevent bending of the needle.
Mandible
Fig 4 (right) The injection points are close to the
cervix.

Fig 5 (below right) Injection pressure must be

maintained without interruption throughout the
injection (based on Harnisch9).

Injection points

onds or more, anesthesia sets in without

latency.
Anesthesia of the individual tooth is deep,
but of relatively short duration. Depending on
the indication, this can be an advantage for
the patient because sensitivity is completely
restored after only about 30 minutes (Table 2).
By injecting additional smaller quantities of
anesthetic agent, it is possible to extend the
anesthetized area and prolong the duration of
the anesthesia.

MECHANISM OF ACTION

ILA is an intraosseous anesthesia, similar to

infiltration anesthesia. The injected anesthet-
ic is distributed by passing through the crib-
form plate and the medullary bone spaces in
into the vasculature in and around adjacent
teeth.10,11The sensitive nerve endings of
nervus mandibularis or nervus maxillaris
pass through the apical foramen into the

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Table 2 Results and criteria of tolerability of 3 anesthesia methods7

Questions ILA Infiltration anesthesia Nerve block anesthesia

Total no. of anesthesias applied 202 225 202

No. of patients 137 151 149
No. of cases requiring follow-up injection 15 (7.4%) 29 (12.9%) 42 (20.8%)
Average amount of anesthetic injected 0.43 mL 1.67 mL 1.84 mL
Pain upon injection 13 cases 58 cases 42 cases
(6.4%) (25.8%) (20.8%)
Average latent period after injection* Practically no latent period 3.4 min 3.3 min
Average duration of anesthesia* < 30 min 2.98 h 3.86 h
Impairments (numbness, Elongation sensation, 2 Numbness, 207 Numbness, 199
cardiovascular reactions, other) Numbness, 2 Crying, 6 Cardiovascular reaction, 11
Cardiovascular reaction, 4
*As stated by the patients.

pulp; however, the endings of these nerves
are also located in the periodontal tissues,
namely, alveolar bone, gingiva, and connec-
tive tissue. The intraligamental injection of an
anesthetic thus produces an immediate
desensitization of the nerve endings sur-
rounding the tooth and of the pulpal nerves.
In certain cases, described in the relevant
literature, more than 1 tooth—usually 2—was
anesthetized with 1 intraligamental injec-
tion.12 For prolonged interventions, eg, endo-
dontic treatment, a follow-up injection is pos-
sible without any problems, but other injec-
tion points should be selected.
INDICATIONS AND
CONTRAINDICATIONS
ILA is an anesthesia method offering advan-
tages for clinician and patient for any type of
minor intervention on a single tooth:
• Restorative procedures at individual teeth,
including cavity and crown preparations.
• Endodontic treatment with the possibility
of follow-up injections.
• Subsequent injection under rubber dam.
• Tooth extractions in permanent dentition.
• Completion of partial anesthesia failures
of other anesthesia methods. A partial fail-
ure of nerve block anesthesia can often
be completed by ILA.13–15
ILA offers particular advantages in:
• Differential diagnosis of symptoms of pul-
pitis of uncertain origin and irradiating
pain. Since with ILA every tooth has to be
anesthetized individually, sensitivity can
be tested tooth by tooth.7,12
• Patients with cardiovascular risks, be-
cause of the small amount of anesthetic
required.12,14
• Patients with hemorrhagic diathesis and
those treated with an anticoagulant. Other
methods of local anesthesia are con-
traindicated in these patient groups.16
• High-risk patients after myocardial infarc-
tion with cardiac bypass and those with
other cardiovascular diseases.14
ILA is especially suitable for the treatment
of children and disabled individuals, since the
puncture produced by the fine injection nee-
dle is unlikely to cause intense pain. Moreover,
there is no evidence of numbness in cheeks
and the labiolingual area, so there is a much
lower risk of postoperative bite injuries.8,17
Fear of injections, a common phenome-
non in dentistry, can largely be avoided
through the use of “friendly” instruments such
as Citoject or SoftJect. These instruments
look more like a fountain pen than the com-
monly used syringe. Syringes that do not look
like syringes are beneficial to the patient’s
imagination. However, for some overanxious
patients, they do remain syringes.

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The only restriction from a medical view-
point is the possibility of hypoplasia in asso-
ciation with periodontal injections in primary
teeth. Evidence of this phenomenon was
suggested by Brännström et al in a study
published in 198418; the causes are still
obscure. The possibility of bacteremia men-
tioned in isolated reports in the relevant liter-
ature has not been confirmed by the authors
during more than 15 years of large-scale clin-
ical and practical use.
Particular caution must be observed,
however, in endocarditic-prone patients
because a settling of bacteria from blood
may lead to serious complications for the
patient. In particular, invasive operations
must be performed under antibiotic protec-
tion. This protective measure has to be
observed not only with ILA but also with
other manipulations at the gingival sulcus,
eg, odontexesis.19 Glockmann et al12 define
that the risk of endocarditis is an absolute
contraindication for ILA.12
LIMITATIONS
For extensive surgical operations, ILA will not
cover the needs because of the limited dis-
persion of the injected anesthetic solution and
the relatively short duration of the anesthesia.
Although it is possible to extend the area of
analgesia by increasing the number of injec-
tion points, ILA should not be used for longer-
lasting, widespread surgical operations.
DENTAL PRACTICE
Material and methods
The tolerability of ILA in association with tooth
extractions was assessed by Heizmann in
comparison with nerve block and infiltration
anesthesia.20 At the same time, the rates of
postanesthesia wound healing disorders were
determined. For this purpose, patients were
divided into 3 groups, and a total of 110 teeth,
both maxillary and mandibular, were extract-
ed. This study was based on a double-blind
design, and the local anesthetic injected was
articaine hydrochloride 4% with adrenaline
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1:200,000. With regard to wound healing dis-
orders, no significant differences were found.
In 2002, Dirnbacher7 compared the con-
ventional methods of local dental anesthesia
with ILA in healthy adult patients and con-
cluded that in all aspects, ILA is at least com-
parable and partly significantly superior to
the other methods (see Table 2).
To evaluate the different armamentaria
applied by Heizmann and Dirnbacher for
intraligamental injections, ie, dosing lever
and dosing wheel syringes, the two syringe
types were used in parallel in a study by
Zugal8 (Table 3). According to the working
hypothesis that ILA is indicated to an unlimit-
ed extent for the indications defined, in
Zugal’s practice,8 local anesthesia was per-
formed for restorative cases, endodontic
cases, extractions, and other treatments,
such as crown preparations, gingivectomies,
and retraction cord placement.
Initially, the injection systems Citoject and
SoftJect, trade standards, were applied about
equally for the injections. In the course of the
practical application, the dosing wheel syringe
SoftJect proved to be sensitive and more
favorable for the anesthesia success intended.
On account of the direct pressure trans-
mission—without intermediate levers—the
back-pressure to be overcome could be felt
without any limitations. The different anatom-
ic conditions were partly the reason for a
reduced or increased back-pressure that had
to be overcome. In the case of excessive
back-pressure, the clinician was able to
select a different injection point, where a
lower back-pressure had to be overcome
with a lower tissue density.
Over time, the SoftJect syringe was
almost exclusively used (82.9% of the cases)
because of its superior results. The Citoject
syringe, however, with its sensitive handling,
can be used for ILA without any restrictions.
Results
The injection pain noted in 27 cases (13.2%)
was reported overproportionally by children.
To reduce the sensitivity of the gingiva, it is
recommended that a drop of anesthesia be
deposited at the insertion point on the sulcus
before insertion of the dental needle into the
gingival crest. This is particularly easy to exe-
cute with the dosing wheel syringe.
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Table 3 Clinical results of 205 documented cases of ILA8*

Teeth treated† 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
1 6 14 6 5 10 5 8 6 6 9 3 4 13 7 0
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
2 6 15 7 9 1 0 1 0 2 1 1 8 10 13 2
55 54 53 52 51 61 62 63 64 65
2 1 0 0 0 0 0 2 5 2
85 84 83 82 81 71 72 73 74 75
1 3 0 0 0 0 0 0 4 4
Indications Restorative treatments Endodontic treatments Extractions Crown preparation (6)
Gingivectomy (3)
Placement of retraction cord (10)
153 cases 3 cases 30 cases 19 cases
74.6% 1.5% 14.6% 9.3%
Patient category Normal patients Risk patients Children Children with disabilities
96 4 31 1
72.7% 3.0% 23.5% 0.8%
Operation time,
including latent time Up to 10 min 10–20 min 20–30 min > 30 min
45 cases 64 cases 71 cases 25 cases
Injection pains Yes No
13.2% 86.8%
Injection latency time Practically nil
203 cases
99%
Injection quantity initial 0.2 mL 0.4 mL 0.6 mL > 0.8 mL
71 cases 55 cases 75 cases 4 cases
Subsequent injection No Yes Method Quantity on average
required ILA 13, NB 1, 0.35 mL
191 cases 14 cases IA 1
Anesthesia complete Yes—with subsequent Yes—with subsequent
(success) Yes—initial injection (ILA) injection (NB) No (failure)
188 cases 12 cases 1 case 1 case
91.7% 5.9% 0.5 % 0.5%
Duration of anesthesia 20–30 min Approx. 30 min 30–40 min 180 min (= NB)
3 cases 196 cases 4 cases 1 case
1.5% 95.6%? 1.96% 0.5%
Impairments mentioned Numbness Circulatory stress General impairments
1 case (= LA) 0 cases 0 cases
(NB) Nerve block; (IA) infiltration anesthesia; (LA) [Au: What is LA, under duration of anesthesia?]
*A total of 205 teeth in 132 patients were anesthetized in 186 sessions.
†FDI system of tooth numbering.

The initial anesthesia success was 91.7%
(188 of 205 cases), and the overall rate of suc-
cess increased to 97.6% with subsequent ILA
injections (12 cases). Three patients tolerated
minimal pain. Anesthesia in 1 patient was
completed by means of nerve block anesthe-
sia; 1 case (a maxillary left second molar)
proved to be resistant (anesthesia failure).
With the exception of anesthesia failure,
practically no latent period was noted
between injection and initiation of the anes-
thesia effect.
The quantity of anesthetic solution inject-
ed per tooth largely depends on how many
roots the tooth has. The quantity mentioned
in the literature1,12,14—about 0.2 mL per tooth

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Table 4 Indications for local dental anesthesia

Indications ILA Infiltration Nerve block

anesthesia anesthesia

Extensive treatment in the mandible Conditional No Yes

Treatment in the anterior area Yes Conditional No
Treatment in the maxilla Yes Yes No
Single-tooth anesthesia for restorative treatments Yes No No
Diagnosis of symptoms of pulpitis of unclear origin Yes Impossible Impossible
Patients with hemorrhagic diathesis Yes Conditional Contraindicated
Patients with cardiovascular risks Yes Conditional No
Endodontic treatment Yes Conditional Conditional
Single-tooth extractions and minor surgical operations Yes Conditional No
Extraction of primary teeth Conditional Yes Conditional
Completion of incomplete nerve block anesthesia Yes Conditional No
Prevention of postoperative injuries,
eg, in children and disabled individuals Yes Conditional No
Reduction of fear of injection Yes, with No No
penholder-type syringes

root—coincides with our results. As the
individual case allows, this quantity can be
slightly increased to safeguard an immediate
anesthesia result. The quantity of anesthetic
solution used for ILA is, in any case, always
significantly smaller than for a conventional
inferior alveolar nerve block or infiltration
anesthesia.
The duration of the anesthesia was about
30 minutes in 95.6% (196) of cases; this
duration was confirmed by Dirnbacher, too.7
After this time, the sensory capacity was
completely restored.
The impairments mentioned in the litera-
ture, primarily the elongation sensation and
the pressure pain after the fading of the anes-
thesia, were not reported by any of the
patients. One reason for this is the clinician’s
many years of experience with the periodon-
tal ligament injection method. Another deci-
sive reason is the exceedingly slow and
sensitive injection of the anesthetic into the
periodontium, which allows the tissue sur-
rounding the tooth to resorb the anesthetic
solution injected. The anesthetic was inject-
ed slowly in a controlled manner (> 20 sec-
onds for 0.2 mL per root).
No wound healing disorders (ie, dry sock-
et) were reported for any of the extraction
cases. This can probably be attributed, as
stated by Heizmann and Gabka,14 to the lege
artis applied method of the periodontal liga-
ment injection.
Table 3 shows the details of the clinical
coverage of the 205 ILA treatments.
DISCUSSION
The results show that the ILA method does
not bear any unreasonable risks in the
course of routine, practical application when
exercised under the defined conditions.
Neither are any undesired effects caused.
For the clinician, but also much more for
the patient, the ILA method offers many
advantages in comparison to the convention-
al dental nerve block and infiltration anesthe-
sia methods:
• The largely immediate onset of anesthesia
without latent periods permits treatment
to start immediately without interruption of
the work process.
• Anesthesia of a single tooth enables treat-
ment of teeth in different quadrants during
a single visit.
• Because of the short anesthesia duration
and the absence of numbness in the
cheek, tongue, and lips, the patient can
resume professional and social commit-
ments immediately after treatment without
any limitation.

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Endo et al
• There are practically no anesthesia fail-
ures; if required, subsequent injections, to
a large extent, complete the analgesia.
• In patients with an unstable cardiovascu-
lar system, the cardiovascular risk is
markedly reduced.
• Patients with bleeding disorders can lege
artis be treated with the ILA method, with-
out additional expenditure.
• In children and disabled persons, the risk
of postoperative bite injuries is markedly
reduced.
• When using the instruments described for
this treatment, the syringe has partly lost
its frightful appearance.
In addition, bacteremia, sometimes men-
tioned in relevant publications, has not been
observed in the 15 years the authors have
been using this technique in large-scale
clinical and practical use.8,14 It must be
emphasized, however, that particular caution
must be observed with endocarditic-prone
patients because a settling of bacteria from
the blood may lead to serious complications
for the patient. In particular, invasive opera-
tions must be performed under antibiotic
protection. This protective measure must be
observed not only in the case of ILA but also
with other manipulations at the gingival sul-
cus, eg, odontexesis.19
The modern syringe systems of the third
generation for ILA—the dosing wheel syringes,
such as the SoftJect—permit every clinician,
with some practice, to perform the ILA method
successfully.
Pistol-type syringes have not been includ-
ed in the clinical evaluation because with
these syringes, even those with pressure lim-
itation, the pressure to be induced (100 N,21
corresponding to about 2.7 MPa) markedly
exceeds the tolerable limit values for opera-
tions to preserve teeth. With the SoftJect
syringe, pressures—precisely controlled by
the clinician—of less than 0.1 MPa (equivalent
to 1 N/mm2 or 0.1 bar) were measured.22,23
In a comparison of SoftJect to Citoject,
the dosing wheel syringe offers significant
advantages over the dosing lever syringe for
the clinician. With the dosing wheel syringe,
eg, the SoftJect, a precise pressure genera-
tion is possible. The clinician immediately
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e24
feels the back-pressure to be overcome in his
or her hand because no levers increase the
forces applied in this injection system. When
the dosing wheel no longer allows itself to be
rotated, then the tissue back-pressure has
become excessive. This means that another
injection point needs to be selected to con-
serve the anatomic structures.
At the end of the injection, rotating the
dosing wheel back can reduce the pressure
so that the anesthetic agent is prevented
from flowing into the mouth and leaving an
unpleasant taste.
A recommendation for hypnosis clinicians:
Because with the ILA method, neither an
injection pain nor a feeling of numbness is felt,
the treatment has a without-syringe effect and
offers an additional advantage for the clini-
cian.
It has been observed from practical appli-
cation that some patients are satisfied only
with a marked feeling of numbness and
believe that only then has the anesthesia
become effective. In such a case, an infiltra-
tion or inferior alveolar nerve block anesthe-
sia is indicated to exclude the subjective sen-
sation of an anesthesia failure.
For the first time, with the SoftJect system
(that is, with injection armamentarium and
system-adapted needles), a set of instru-
ments is available that enables the clinician
to achieve sufficient pain elimination, under
precisely controlled conditions, with great
care, safely, and almost completely without
anesthesia failures for almost all types of den-
tal treatment.24
CONCLUSIONS
Intraligamentary anesthesia has thus proved
to be a valuable technique in the dental prac-
tice. Since the introduction of optimally suit-
ed instruments and injection needles—the
dosing wheel syringe SoftJect being a par-
ticularly innovative and user-friendly system—
local dental anesthesia has lost its unpleas-
ant adverse effects for the patient. For the
clinician, the ILA method offers many advan-
tages for normal interventions. When com-
paring the ILA method with the conventional
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methods of local anesthesia, ILA proves
superior in all parameters documented7 (see
Tables 2 and 4).
From the practitioner’s point of view, ILA is
an indispensable method of eliminating pain
in most dental interventions. The dosing
wheel injection system—consisting of syringe
and injection needles—has been available
since 1998. The pinpoint application of an
exact minimal dose of anesthetic under con-
trolled high pressure ensures anesthetic suc-
cess in a high percentage of cases. Adverse
effects occur only in rare cases. The precision
of the SoftJect syringe, the very fine, specially
adapted injection needles, and the possibility
of minimal dosage open up an even wider
range of application for this system.
The experience gained with ILA in dental
practice is positive. Any progress in our dis-
cipline, including that with local anesthesia,
should be widely taught, especially if our
patients will derive great benefit from a new
technique.14
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