Twelve alternatives to the traditional inferior alveolar nerve block.

In the case of the difficult-to-anesthetize patient, the inferior alveolar nerve can be particularly challenging. In those patients, other approaches may be necessary to achieve profound anesthesia. This article presents techniques that may be utilized in those efforts. The clinician can change his target slightly, or increase the dosage of anesthetic. Accessory innervation by lingual and mylohyoid nerves sometimes needs to be addressed. Some standard alternative approaches are Gow-Gates and Varizani-Akinosi injections. Intra-osseous and intraligamentary injections should be considered. For lower anteriors, infiltration and incisive nerve blocks can effective. Slight changes in armamentarium like increasing the needle gauge can be helpful. Twelve approaches are described which can be used instead of, or as an adjunct to, the traditional Halstead injection.