Anesthesia: It’s Simple…’Till It’s Not

anesthesia efficiency pdl syringe Jan 26, 2021

We’ve all been there. It’s your big case for the day.  Maybe, you’re part way through the procedure and your anesthesia starts failing. Or it’s the patient that needs to be completed so the rest of the day’s schedule doesn’t fall apart. Maybe the patient is scared to death and you’re trying to win them over with this first procedure. Or it’s the new procedure that you’re trying for the very first time. 

And now…the patient isn’t getting numb. Time is ticking away.  Even though you allowed enough time (even a little extra), now it’s all gone. The staff have started cruising by the operatory like sharks that smell blood in the water. 

They’re looking at their watches, tapping their feet and wondering what’s going on. And so are you. Can you tell I’ve been here before? 

If you have as well, stay with me.  I’ll tell you what my biggest game changer was.

The Game Changer

It’s the PDL injection given a little differently.  Adjusted slightly so that my success rate is 100%! Now, I’m certain that at some point I’ve given this injection and not gotten profound anesthesia but, I honestly can’t remember when.


This is my second injection if the patient isn’t numb with the primary anesthesia. Like a missed IAN block. Rather than blocking again and then waiting another 5-10 minutes (can you hear the clock ticking?), you can give this injection and start work immediately. Onset of anesthesia is immediate. Or how about, when you’ve placed a rubber dam and now discover that the patient isn’t numb? You won’t need to remove the rubber dam.  Just inject between the clamp and the tooth or mesial to the clamp.

It can be used as a primary injection if an infiltration is unwanted or impractical (mostly mandibular molars)


I use a “pistol-style” PDL syringe that “clicks” as the plunger is advanced.  It lets me know how many “clicks” I’m giving so I have a feel for how much anesthetic the patient has received. 

The “non-click” syringes are just fine. They work great.  I just don’t get the feedback.

Could you use a regular syringe or a pencil-style PDL syringe?  

Yes, but…

  • The regular syringe won’t allow you to develop the same pressure that the pistol-style will.  
  • The pencil-style doesn’t allow for the attachment of the Vibraject which was my secret to success with this injection.

So, what is the Vibraject?  

It’s that little grey and green thing attached to the barrel of the syringe. And all it does is vibrate.

It’s the secret to success because it helps to better seat the needle at the tooth/alveolus interface.  This is the critical step to getting anesthetic where it needs to go.

While the injection can be given at any of the tooth/bone interfaces, I’m usually giving it as far into the mesial interproximal space as possible or in the furcation area.  The distal and lingual are harder to access but will also work just as well.

Which Anesthetic? 

I like Septocaine with 1/200k Epi. But then again, I like Septocaine everywhere and for every injection.  But especially for this injection, Septocaine is my “go to”.

It diffuses better and seems to give more profound anesthesia when compared to Lidocaine.

How about patients that are “allergic” to the epinephrine?  First off, if that were true, they’d be dead because their body produces way more epinephrine than is found in a few carpules of anesthetic.  However, I get that many patients don’t like the feeling of the epinephrine rush.  

Unless they are VERY sensitive to epinephrine most patients won’t feel any effects of the few drops of anesthetic that is administered with the PDL injection. (Again, I’m sure it’s happened but, I honestly can’t remember when).  Just be sure you’re only administering a few “clicks”.   Maybe 1/5 to 1/4 carpule of anesthetic at most.

Which Needle?

30 guage and super short. You’re placing pressure down the long axis of this needle.  Long needles bend and won’t allow delivery of the anesthetic  


  1. Place a bite block if giving the injection on the mandible (which is 95% of the time).You’re going to be placing significant pressure down the long axis of the  needle.  Any movement in the mandible will cause you to “crunch” the needle necessitating replacement and restart.  This will happen frequently as you’re learning the technique anyway. Stack the deck in your favor.
  2. Place a cotton roll in the vestibule. Not all of the anesthetic will go into the PDL space and it tastes really bad
  3. Choose your site, place needle into sulcus with pressure down its long axis. If you “crunch” the needle, start again.  This WILL happen sometimes. 
  4. Inject: 

         You should feel significant back pressure

  •       Too much = the plunger isn’t advancing. No anesthetic is being given
  •       Too little = you’re not feeling resistance. Anesthetic isn’t being forced down the PDL space.


  • Tissue sloughing at the injection site 
    • Usually from too much pressure.  Hurts but will heal fine. 
    • Recommend symptomatic relief for the patient.
  •     Broken carpule in the syringe 
    • Again, too much pressure.  If the anesthetic isn’t moving, reposition the needle. Too much back pressure is a hint that things aren’t lined up properly 
  •    “Crunched” needle
    • Be sure patient is stable with a bite block.  Pay particular attention to angle that the pressure is being applied to the needle.

Final Thoughts

“All in” the syringe and the Vibraject will probably cost $400 or so.  It sounds a little pricey until it saves the day a time or two.  Then you won’t be able to live without it.  

In my office, we lay out the syringe every time we treat a mandibular molar.  Most of the time it isn’t needed but, when it is, this saves the inevitable wait for the assistant to run to the lab, find it and bring it back.

So now re-imagine our starting scenario…

 It’s that critical appointment of the day.  

We’re trying to do a great job of treating the patient and winning them over.  Also, for the first time we’re trying a new more productive procedure that we want to introduce into the office.

So, we need to win over the staff as well.

We have enough time but after waiting for anesthesia to take effect the patient isn’t getting numb. However, in this scenario, we know that we can pull out the PDL syringe with the Vibraject attached, give an injection and in two minutes have a numb patient and be ready to start the procedure.

How much calmer and at ease do you think your procedure and the rest of your day will be now? How much more will the patient trust you because you weren’t like all the other dentists that hurt them? How much more likely will they be to get the rest of their work done in YOUR office? How much more confidence will your staff have when recommending you as the doc that the patients should trust? 

All from spending $400 and learning an anesthetic technique that truly was a game changer in my office.

Feel free to message me with any questions about this or any other topic about efficiency, productivity or any of our courses.