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Anxiety and pain related to mandibular block injections212IntroductionEffective pain control is an important aspect of dental care and can be achieved with oral local anesthetic injections; however, the injections are not pain free and some patients are afraid of receiving local anesthesia.1 In the Netherlands, an estimated 16.1% of patients report anxiety about injections and approximately 1% of the population suffers from injection phobia.2 The two most common dimensions of oral injection fear are the pain of injection and bodily injury.3 There are a number of factors associated with the pain caused by oral injections, such as gender, type of anesthetic fluid, amount of injection fluid, injection pressure4, expertise of the operator, the location of the injection, and the methods of injection.5 Other variables that are possibly related to pain as a result of oral injections are differences in needle gauge, temperature of the injection fluids, and mandibular block injection techniques. However, one study found that needle gauge is not related to the pain from oral injections.6In addition, results from another study7 showed that differences in mandibular block injection techniques did not influence pain. Psychological factors, in particular anxiety, appear to play an important role in the perception of pain. It is well known that anxious people tend to feel more pain.8 It is obvious that the relationship between anxiety and pain can also be found in dentistry.9According to earlier research10,11, anxious people with negative experiences with oral injections appear to feel more pain during an oral injection.Based on an earlier report11, mandibular block injections can be considered mildly painful, with pain lasting only a few seconds for the majority of patients. A mean score of 2.4 was given for pain on an 11-point numerical rating scale (NRS). About 8% of patients experienced the mandibular block injection as very painful, with a score ≥7. It would be interesting to see whether this difference in perception is the result of primarily psychological processes (such as anxiety and previous experiences with dental injections) or can be accounted for by biological differences (more sensitivity to pain leading to a stronger physiological response). Therefore, in the present study, pain from mandibular block injections was studied using psychological questionnaires and physiological responses (heart rate [HR], galvanic skin response [GSR], respiration [RSP], and blood oxygen