Effective anesthesia is a frequent challenge in endodontics, particularly in symptomatic mandibular molars with irreversible pulpitis. A layered approach combining profound regional block, buffered solutions, and supplementary techniques is often required.
- Lidocaine 2% with 1:100,000 epinephrine — baseline infiltration and block.
- Articaine 4% with 1:100,000 epinephrine — superior diffusion, useful for buccal infiltration in mandibular molars; some controversy around IAN-block paresthesia risk.
- Mepivacaine 3% plain — short procedures, cardiac patients.
- Bupivacaine 0.5% with 1:200,000 epinephrine — prolonged post-operative analgesia.
Sodium-bicarbonate-buffered lidocaine (pH ~7.4 vs 4.0 unbuffered) provides faster onset and less injection pain. Commercial buffering devices (e.g., Onset) or chairside mixing.
- Intraosseous anesthesia (X-Tip, Stabident) — deposits solution directly into cancellous bone; onset < 1 min, reliable for irreversible pulpitis.
- Intraligamentary injection — useful for single-tooth targeting; limited volume.
- Intrapulpal injection — last-resort, pressure-dependent; brief but effective.
- Gow-Gates or Vazirani-Akinosi — higher IAN-block success in anatomically difficult cases.