**7. Pain management**

### **7.1 Supplementary anesthesia**

#### *7.1.1 Intraligamentary anesthesia*

Intraligamentary anesthesia is a technique wherein local anesthetic solution administered via the periodontal ligament to reach the pulpal nerve supply. The use of conventional or customized syringes can be used for this technique. At the mesiobuccal aspect, the needle is placed as deeply between the root surface and alveolar bone at a 30° angle to the long axis of the tooth. The needle can be placed with the bevel pointing in either direction, and 0.2 ml of the solution should be injected per root using back pressure. For 5 to 10 seconds, the needle is held in place [31]. The anesthetic action begins almost immediately and lasts for around 15–20 minutes [32].

In comparison to other anesthetic techniques, Intraligamentary anesthesia allows for a substantial reduction in the overall volume of anesthetic solution and vasoconstrictor supplement. At the same time, the unintentional intravascular application is avoided [33]. Furthermore, the effectiveness of Intraligamentary anesthesia is limited in cases of severe marginal periodontitis or teeth with a sclerotic periodontal gap, and alternate anesthetic methods such as inferior alveolar nerve block can be advised [32].

#### *7.1.2 Intraosseous anesthesia*

Intraosseous Anesthesia is more invasive and necessitates the use of specialist equipment, such as a perforator (e.g., Stabident, X-Tip). The gingiva must first be sedated for the perforator to penetrate without discomfort. A slow-speed handpiece is used to move the perforator into the anesthetic gingiva and bone until the cancellous bone is felt like a sharp dip. The perforator is then withdrawn, and a small 27-gauge needle is introduced through the perforation, injecting approximately 1 mL of solution over 2 minutes. It's one of the most effective supplemental methods available [34]. The intraosseous injection permits the local anesthetic solution to be injected directly into the cancellous bone adjacent to the tooth that has to be sedated [35]. The intraosseous anesthetic onset of anesthesia is immediate and lasts for around 15 to 30 minutes, and was found to be more efficient than intraligamentary anesthesia [36].
