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Anesthesia Supporting Your Practice

Conversation Opener: What are the key issues in intraosseous anesthesia?


Isen editedIn this video presentation, Dr. David Isen speaks about the key issues in intraosseous anesthesia and how it applies to the practitioner’s ability to use anesthesia safely and effectively.


If doing an intraosseous injection, practitioners should inject LA slowly in order to limit the increase in heart rate.



Intraosseous anesthesia steps:

  • Take a bitewing radiograph to ensure sufficient bony space between the roots.
  • Apply topical anesthetic.
  • Do a preparatory infiltration so the perforation is painless.
  • Do the perforation over attached gingiva. The perforation should remain perpendicular to the buccal cortex. The perforation should be done in a pecking motion for less than 5 seconds.
  • Slowly inject 1/2 a cartridge of local anesthetic over 30 seconds to 1 minute.
  • Use a maximum of 1 cartridge of local anesthetic per appointment.

Watch the Video 


Dr. Isen completed a Bachelor of Science degree in neuroscience from the University of Toronto and graduated in dentistry from the University of Western Ontario. Following his graduation, Dr. Isen underwent advanced training in intravenous sedation at the Montefiore Medical Center in New York which has focused his dental practice on patients requiring special care for their treatment. Dr. Isen lectures widely on topics related to local anesthesia and medical emergencies. He is past president of the Ontario Dental Society of Anaesthesiology and has acted as a reviewer for dental journals and published a number of his own articles.



  1. Stephen Leung March 31, 2015

    Dr. Isen, thank you for a most informative presentation regarding Intraosseous anaesthesia. I am sure most dentists are aware of some of the problems associated with the technique but you have presented them in a well organized and useful manner to take the fear out of the using the technique.

  2. Dr. Sylvie Renoir March 31, 2015

    I’ve had great success with this technique using the Stabident system. Immediate onset, short duration and no frozen tongue. Patients love it.
    Comes in really handy for those patients who are hard to block.

  3. Dr. Ken Miller March 31, 2015

    Hello Dr. Isen,
    Thank your succinct presentation on Intra-Osseous Anesthesia. In your video you say we should only use one cartridge of anesthetic with vasoconstrictor 1:100,000 epinephrine per appointment because of the vasoconstrictor sequelae. I use Orabloc (articaine with 1:200,000 epinephrine). Would I be safe to construe I could use 2 carpules for IOA if wanted on a normal healthy adult in one appointment?
    Thank you for your time and expertise, Ken.

    1. Anonymous April 6, 2015

      Hi Dr. Miller,

      Thanks for your comments. I think it is a reasonable approach – to be able to use a little more anaesthetic with less vasoconstrictor for intra-osseous injections (even though the opposite holds true for standard injections).

  4. Dr Andrew Nette April 1, 2015

    I have used intraosseous anesthesia for many years, as my primary anesthetic for small restorative lesions, for removal of lower bicuspids for orthodontic purposes, and as an adjunct to IAN block if I am having trouble settling a ‘hot’ mandibular tooth.
    In my experience, the frequency and morbidity of the “epinephrine rush” when employing LA with epinephrine in this technique has resulted in my preference for using plain (no epi) anesthetic. Even though I use 1:200,000 epi anesthetic for my routine procedures, I find that dose, even with my standard 1ml volume for intraosseous, too disquieting for most patients.
    I will only use the 1:200,000 epi LA in the intraosseous site if I am having trouble completing my project before the plain anesthetic starts to wear off…..I then find that the epinephrine not only prolongs my anesthesia, but does not seem to give the same ‘rush’, perhaps due to the dilution by way of solution already in the medullary bone.

  5. Milan Somborac April 7, 2015

    In a Feb. 6, 2015 Oasis interview with Dr. O’Keefe I reported on 100 patients consecutively treated in both arches using nothing but intraosseous anesthesia. Our success rate was 89% for all procedures including simple restorative work, crown and bridgework, endodontics, simple surgery, implant surgery, wisdom teeth extraction and flap surgery.
    Dr. Isen’s excellent presentation raises physical and pharmacological challenges of achieving effective IOA using the Stabident and the X-Tip instruments and protocols. The physical issues are difficulty of access to posterior areas and of penetrating thick cortical bone. The pharmacological issues are heart rate increase and risk of toxicity especially in patients with cardiovascular disease.
    In our study we overcame the physical problems by modifying the 100 year-old technique of using a handpiece, bur then needle and syringe. The old method used a slow handpiece and a latch bur. We used a 45° high speed handpiece and a friction grip oral surgery bur (Alpen Carbide 171). This allowed easy access to all posterior areas as well as to the rarely used but frequently useful lingual and palatal regions.
    We overcame pharmacological problems by using 3% Carbocaine (Mepivicaine) without a vasoconstrictor.
    As Dr. Isen states, the significant advantages of IOA are rapid onset, no lip, tongue or facial muscle anesthesia, no hematomas, no trismus, no physical nerve damage. Like with all techniques, there are disadvantages, of course. He quotes a 2006 Dental Products Report showing that 20% of dentists use IOA whereas 45% of endodontists do so. (Frequency of use was not stated.)
    IOA could become more common for its significant benefits if a 45° high speed handpiece and a FGOS bur are used to deliver 3% Carbocaine (Mepivicaine) without a vasoconstrictor to the operative site. What the profession needs is a well-planned, controlled study. Hopefully, someone will rise to the task.


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