23] (15.3%) and Nooh and Abdulla[@ref20] (1.7%).

Finally, our data regarding the participants' self-reporting of their knowledge of and training with alternative techniques indicate clearly that both are lacking. The portion of students and interns in our study who felt they had both sufficient knowledge of and training in alternative techniques (9.3%) was far smaller than that reported by similar to the close to 90% figure reported by Johnson et al.[@ref15] This massive discrepancy is likely due to students at Harvard School of Dental Medicine students and graduates receiving far greater instruction related to alternative methods, including the Gow-Gates and Vazirani-Akinosi techniques.[@ref15]

In conclusion, the results of the present study indicate that the dental curriculum at King Saud University is lacking in coverage of techniques that can be employed when an IANB fails or is contraindicated. To decrease the IANB failure rate, instruction related to anatomical landmarks, anatomical variation, and pre-IANB aspiration should also be enhanced.

Enhance education of alternatives to IANB, such as the Gow-Gates and Akinosi techniques, both theoretically and clinically, in the anesthesia courses of the dental curriculum; enhance knowledge of anatomical landmarks for IANB administration; train students how to select the most appropriate alternative technique; increase supervision and training of various techniques; and it should be emphasized that aspiration is mandatory before any anesthetic technique, including conventional IANB are some of the recommendations.

*We would also like to express our gratitude to Mr. Nassr Al Maflehi for his assistance in completing the statistical analysis. The authors thank the College of Dentistry Research Center and the Deanship of Scientific Research at King Saud University, Saudi Arabia for funding this research project. Our great appreciation is also extended to all students and interns who participated in this survey*.

**Disclosure.** Authors have no conflict of interest,