Provide supplemental local anesthesia:

Aim higher on the 2nd IAN block: Gow–Gates or Vazirani–Akinosi (closed mouth mandibular block) (Fig. 4.3a, b).

Mental nerve block: The mental foramen can also be located via palpation, periapical radiographs, and panoramic radiographs (Aminoshariae et al. 2014). Additionally, the average location of the mental foramen is 60 % of the distance from the tip of the buccal cusp of the mandibular 2nd premolar to the inferior border of the mandible (Phillips et al. 1990).

Use an anesthetic with a lower pKa 3% mepivacaine since it decreases the potential for ion trapping, increases the concentration of local anesthetic molecules in their base form, and increases diffusion of the LA across nerve terminals, thus increasing onset of anesthesia.

Adjunctive injections: intraligamentary, intraosseous (IO), intrapulpal (see descriptions below in Section 2).

Adjunctive drugs: fast-acting nonsteroidal anti-inflammatory drugs (NSAIDs). Ibuprofen in a liquid gel form reduces levels of inflammatory mediator prostaglandin E₂ (PGE₂); this is a hypothesis and has not been evaluated in endodontic patients.

Anxious patients may benefit from nitrous oxide prior to giving any type of injection. Additionally, anxiolytic therapy my also be provided for the patient prior to their dental appointment. These medications are both safe and effective for dental outpatients. Studies have shown that triazolam (0.25 mg) can be an effective anxiolytic than diazepam (5.0 mg) for endodontic patients (Erich et al. 1997). Provide the patient with a prescription for two tablets of triazolam (0.25 mg), have the patient take one, one hour before their dental appointment, and instruct them to bring the remaining tablet with them to their dental appointment. Side effects include dizziness, drowsiness, and loss of coordination, thus the patient must have a driver accompany them to and from their dental appointment.

Distraction techniques such as jiggling the patient’s lip or quickly pulling the soft tissue over a stationary needle tip may aide in anesthetizing the anxious patient.