If a patient remains unanesthetized after an inferior alveolar nerve block (IANB), what is the recommended next step before proceeding with treatment?

When an inferior alveolar nerve block (IANB) fails to achieve adequate anesthesia, supplemental anesthesia techniques should be used before proceeding. Options include: intraosseous (IO) anesthesia (highly effective for irreversible pulpitis in mandibular molars), periodontal ligament (PDL) injection, intrapulpal injection (if pulp is accessible), Gow-Gates mandibular block, or Vazirani-Akinosi technique. Repeating the IANB at exactly the same site is generally not productive if the first injection was anatomically correct; however, a second attempt at a higher injection site may help. For irreversible pulpitis, IANB failure is particularly common (hot tooth phenomenon) due to lowered pain thresholds from inflammation — IO injection is the preferred supplemental technique.