Inferior alveolar nerve block in mandibular molars with symptomatic irreversible pulpitis: causes of anesthetic failure and how to increase the anesthetic success rate—a narrative review

Introduction

Background

Symptomatic irreversible pulpitis may be classified as a degenerative inflammatory process of the pulpal tissue, without the possibility of healing, which will progress to a state of pulpal necrosis if no clinical intervention occurs (1). It is characterized by spontaneous pain or intense lingering pain after thermal stimulation, even after removal of the stimulus (2). The treatment for this condition consists of endodontic treatment, with the objective of preventing infection of the root canal system and, consequently, the occurrence of apical periodontitis (3,4).

For endodontic treatment, effective pulpal anesthesia is essential, with sufficient anesthetic depth and duration to prevent pain during endodontic procedures and ensure patient comfort throughout treatment (5). In mandibular teeth, the inferior alveolar nerve block is one of the most widely used anesthetic techniques, particularly for the anesthesia of molars and premolars (6).

Rationale and knowledge gap

Clinically, dentists face difficulties in obtaining anesthetic success in mandibular molars. In the absence of symptomatic irreversible pulpitis, the inferior alveolar nerve block has a reported success rate ranging from 58% to 79% (7,8). However, in cases of symptomatic irreversible pulpitis, this success rate may decrease to approximately 2.3% to 29% (9-12). Although some studies suggest possible causes for this failure, few provide practical clinical strategies to improve anesthetic success rates, especially in cases of symptomatic irreversible pulpitis.

Objective

The aim of this review is to discuss the possible causes of inferior alveolar nerve block failure in cases of symptomatic irreversible pulpitis and present clinical strategies to improve anesthetic efficacy, enabling effective pulpal anesthesia during endodontic procedures. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0014/rc).

Methods

The methods are described in Table 1. Briefly, a bibliographic search was performed in the PubMed, Scopus, Web of Science, and Google Scholar databases, from their start dates to May 1, 2026. The descriptors used included [(“inferior alveolar nerve block” OR “dental anesthesia”) AND (“symptomatic irreversible pulpitis” OR “pulp inflammation”)]. Studies published in English and Portuguese addressing different anesthetic techniques used for anesthesia of mandibular teeth, different anesthetic salts, and the use of different preoperative medications were included. Article selection was carried out in three stages: (I) screening of titles and abstracts; (II) reading of the full text of potentially relevant studies; and (III) extraction of key information from selected studies. Data analysis was performed qualitatively, considering the most relevant findings of each study.

Fundamental prerequisites

Before discussing the possible causes of inferior alveolar nerve block failure (and ways to overcome them), it is essential that the clinician consider two fundamental prerequisites: (I) knowledge of the anatomy of the nerves involved; (II) technical proficiency in performing the anesthetic technique. These are fundamental prerequisites because, in order to increase anesthetic success rates, it is essential that the clinician knows the anatomical landmarks of anesthetic importance and is also able to accurately perform the inferior alveolar nerve block technique.

Fundamental prerequisite 1: knowing the anatomy of the nerves involved

Inferior alveolar nerve

It is the largest branch of the mandibular division of the trigeminal nerve. It descends medially to the lateral pterygoid muscle toward the mandibular foramen, where it enters the mandibular canal, providing innervation to all mandibular teeth located on the same side of the dental arch (5).

Mylohyoid nerve

It branches from the inferior alveolar nerve before its entrance into the mandibular canal. It runs downward and forward along the body of the mandible to reach the mylohyoid muscle. It is considered a mixed nerve, containing both motor and sensory fibers (5).

Lingual nerve

It is the second branch of the posterior division of the mandibular nerve. It descends medially to the lateral pterygoid muscle, running parallel (anteriorly and medially) to the inferior alveolar nerve, but without entering the mandibular canal (5). Being responsible for the sensory innervation of the anterior two-thirds of the tongue, it is usually the nerve most involved in cases of paresthesia resulting from the inferior alveolar nerve block technique (13-15).

Fundamental prerequisite 2: technical proficiency in performing the inferior alveolar nerve block technique

Using a long needle (32 mm), the penetration site should be the mucosa on the medial side of the mandibular ramus, between the coronoid notch and the pterygomandibular raphe, approximately 1 cm above the occlusal plane, aiming to deposit the anesthetic in a region close to the inferior alveolar nerve before its entrance into the mandibular canal. The syringe should be angled toward the teeth on the opposite side, using the mandibular premolars contralateral to the anesthetized side as a reference, and the needle penetration depth should be approximately 22 mm (3/4 of the total needle length) (5).

The criterion that may be used to verify correct anesthetic technique is the presence of lip numbness on the anesthetized side after 8 to 10 minutes (10,16). However, lip numbness should never be used to affirm anesthetic success. Studies show that, even with the correct inferior alveolar nerve block technique, anesthetic failure may exceed 70% of cases (17,18). In other words, correct anesthetic technique should not be interpreted as pulpal anesthetic success. Clinical and review studies have reported that electrical and/or thermal pulp tests may be correlated with the clinical success of pulpal anesthesia (19-21).

Causes of failure and solutions

Cause of failure number 1: inflammatory cytokines along the nerve fiber

Pulpal inflammation involves the participation of numerous pro-inflammatory chemical mediators, especially prostaglandins and prostacyclins, which are related to hyperalgesia processes and stimulation of the inflammatory process, including in the periapical region. As a consequence, the pH of the inflamed region decreases to approximately 5 to 6 (physiological pH is approximately 7.4), making the environment acidic (22).

Local anesthetics are compounds with alkaline pH, low solubility, and extreme instability, which would hinder their clinical use and commercialization. For this reason, a weak acid (hydrochloric acid) is added to the anesthetic to form anesthetic salts (lidocaine hydrochloride, articaine hydrochloride, etc.), which possess good capacity to diffuse through tissues and greater stability (23). However, after anesthesia administration, the anesthetic base must dissociate from the hydrochloride, because only the dissociated anesthetic molecules are capable of penetrating the nerve sheath and binding to the ion channel site, thereby producing the anesthetic effect. This dissociation is facilitated in a neutral pH environment.

Thus, the acidic environment resulting from the inflammatory process (pulpal and/or periradicular) results in less anesthetic dissociation and, consequently, difficulty in promoting profound anesthesia (24).

In addition, an animal study conducted in the 1970s demonstrated that, after induction of periapical inflammation in rabbit teeth, histological and histochemical processing revealed degenerative changes in axons and in the myelin sheath of the femoral nerve, that is, very distant from the primary site of inflammation (25). This finding may help explain why, even though the inferior alveolar nerve block is performed in a region distant from the tooth presenting inflammation (pulpal or periapical), high failure rates still occur. Possibly, inflammatory cytokines are capable of causing neural alterations distant from the affected tooth, which could result in pH changes even at a distance, impairing anesthetic establishment.

Solution: preoperative medication with corticosteroids or nonsteroidal anti-inflammatory drugs

Rodrigues et al. (2024) (19), in a randomized clinical trial conducted in patients diagnosed with symptomatic irreversible pulpitis, demonstrated increased anesthetic success rates of inferior alveolar nerve block by orally administering both dexamethasone 4 mg and diclofenac potassium 50 mg one hour before the anesthetic procedure, when compared to placebo administration, without adverse effects regardless of the drug used. One of the points raised to justify the increased anesthetic success is that corticosteroids and nonsteroidal anti-inflammatory drugs, through their anti-inflammatory action, would decrease the acidity of inflamed tissues, increasing the possibility of anesthetic dissociation after their administration. This result is consistent with systematic reviews conducted with the same objective, supporting the effectiveness of corticosteroid and nonsteroidal anti-inflammatory administration prior to anesthetic injection in increasing anesthetic success (26,27).

Cause of failure number 2: choice of anesthetic and volume used

Regarding the type of anesthetic used, although recent clinical trials have demonstrated no differences in the anesthetic success of inferior alveolar nerve block when comparing articaine with other local anesthetics (28,29), systematic reviews with meta-analysis indicate increased success rates when articaine is used (30,31). The increase in success rate when articaine is used may be explained by its high lipid solubility, facilitating bone penetration even in mandibular bone, overcoming possible inaccuracies inherent to the anesthetic technique (5,23).

Regarding the volume used, Abazarpoor et al. (2015) compared the efficacy of using 1 cartridge (1.8 mL) and 2 cartridges (3.6 mL) of 4% articaine with 1:100,000 epinephrine in inferior alveolar nerve block in cases of mandibular molars with symptomatic irreversible pulpitis. The authors observed that when there was an increase in the anesthetic volume used, there was a higher success rate in anesthesia of mandibular first molars (16). This result is consistent with what Aggarwal et al. (2012) had already observed, also comparing the use of 1.8 and 3.6 mL in inferior alveolar nerve block, but using 2% lidocaine (32). These results were also confirmed by two systematic reviews with meta-analyses, which also observed increased anesthetic success rates regardless of the type of anesthetic used (33,34).

A possible explanation for these results is that when a greater volume of anesthetic is used, there is the possibility of exposing at least 6 mm of the nerve to the anesthetic, which would be a condition for effective anesthesia to occur (35). Another possible explanation is that using two cartridges in separate applications would reduce the chances of technical error, increasing the possibility of the anesthetic coming into contact with the inferior alveolar nerve (10,16).

Solution: use two cartridges (3.6 mL) of 4% articaine in an inferior alveolar nerve block

Articaine, besides presenting a higher anesthetic success rate, is a safe anesthetic for use in inferior alveolar nerve block techniques (regardless of volume) (36). The literature does not demonstrate a greater risk of paresthesia (5), and, when compared to lidocaine, it presents lower neurotoxicity (37).

Cause of failure number 3: accessory innervation of the mylohyoid nerve

Another possible cause of inferior alveolar nerve block failure may be accessory innervation of the mylohyoid nerve. Although it is a nerve with motor characteristics, cadaver dissection studies observed that along its pathway, there was the presence of smaller diameter fibers (3 to 6 µm), compatible with sensory nerves, directed toward the lingual portion of the mandibular bone in the region of the mandibular molars (38). This observation, associated with tomographic findings showing small lingual foramina in the same lingual region of the mandibular bone (39), suggests that even with profound anesthesia of the inferior alveolar nerve, electrical impulses generated in mandibular molars could use the mylohyoid nerve as a shortcut, since it joins the inferior alveolar nerve at a region well above the mandibular foramen, where the anesthetic was deposited during the anesthetic technique (40).

Solution: lingual supplemental anesthesia or Gow-Gates anesthetic technique

The intraligamentary anesthetic technique in the lingual region of the tooth to be anesthetized may be used to attempt to increase anesthetic success rates. Aggarwal et al. (2020), in a randomized clinical trial, observed that anesthetic supplementation with the intraligamentary technique increased anesthetic success rates in mandibular molars (41). This finding was corroborated in a recent systematic review with meta-analysis, which also observed increased success rates (42).

Another option to be considered is the use of the Gow-Gates technique instead of the conventional inferior alveolar nerve block technique. Abbasi et al. (2024), in a randomized clinical trial, observed higher anesthetic success rates with Gow-Gates compared to inferior alveolar nerve block (43), a finding also observed in a quantitative systematic review (44). Since in the Gow-Gates technique the anesthetic deposition site is in a superior portion of the inferior alveolar nerve, before the branching of the mylohyoid nerve, there would be a more effective chance of preventing electrical impulse conduction toward the central nervous system, resulting in greater anesthetic effectiveness.

Cause of failure number 4: proliferation of nerve fibers

Another hypothesis that may influence increased anesthetic failure in teeth diagnosed with symptomatic irreversible pulpitis is the increase in the number of nerve fibers in the inflamed region. In an older animal study conducted by Byers et al. (1990), histological analysis demonstrated that after induction of symptomatic irreversible pulpitis in rat molars, there was intense proliferation of nerve fibers both in the pulp and in the periapical region of the injured tooth (45). This intense proliferation would result in dental hyperalgesia associated with difficulty in establishing profound anesthesia.

Solution: buccal infiltrative supplemental anesthesia

Shahi et al. (2018) conducted a randomized clinical trial in patients diagnosed with symptomatic irreversible pulpitis comparing the anesthetic efficacy of the inferior alveolar nerve block alone with the same block associated with supplemental anesthetic techniques. It was observed that, regardless of the supplemental anesthetic technique used (buccal infiltration or intraligamentary), there was a significant increase in anesthetic success when compared with inferior alveolar nerve block alone (46). The intraligamentary injection, because it also acts on the buccal and apical areas of the periradicular tissues, has the potential to act in a manner similar to buccal infiltration anesthesia.

The need to always perform supplemental anesthesia after an inferior alveolar nerve block was emphasized in a systematic review with meta-analysis, where quantitative and qualitative analyses indicated increased anesthetic success rates after supplemental anesthesia. It is important to emphasize that articaine presents more effective behavior in this type of supplementation than lidocaine, both in mandibular molars and premolars (19).

Limitations of this review

This review has some limitations. As a narrative review, no formal risk-of-bias assessment or methodological quality appraisal of the included studies was performed. In addition, the evidence discussed was derived from studies with heterogeneous designs, anesthetic protocols, outcome measures, and definitions of anesthetic success, which may limit direct comparisons among studies. Although several of the proposed strategies are supported by randomized clinical trials and systematic reviews, the available evidence remains heterogeneous, and the findings should be interpreted with caution. Further well-designed multicenter randomized clinical trials are needed to strengthen the evidence regarding the causes of anesthetic failure and the effectiveness of strategies aimed at increasing anesthetic success rates.

Conclusions

The anesthetic success of mandibular molars with symptomatic pulpitis depends on several factors. Since the cause of failure is multifactorial, a clinical sequence is proposed to obtain profound pulpal anesthesia:

• Dexamethasone 4 mg (or a nonsteroidal anti-inflammatory drug), administered orally 1 hour before the anesthetic procedure.
• Inferior alveolar nerve block with 2 cartridges (3.6 mL) of 4% articaine (consider the use of the Gow-Gates anesthetic technique). Verify lip numbness to confirm correct technique.
• Supplemental lingual intraligamentary anesthesia with 4% articaine (0.8 mL).
• Supplemental buccal infiltration with 4% articaine (1.8 mL).
• Always perform electric pulp testing or cold sensitivity tests to verify anesthetic success before endodontic access.
• In case of pain, repeat the supplemental anesthetic techniques.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0014/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0014/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0014/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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