Orthoptic status before and immediately after heroin detoxification.

AIM: To determine whether changes in orthoptic status take place during withdrawal from heroin and/or methadone. METHOD: A prospective study of patients, using a repeated measures design, attending a 5 day naltrexone compressed opiate detoxification programme. RESULTS: 83 patients were seen before detoxification (mean age 27.1 (SD 4.6) years) and 69 after detoxification. The horizontal angle of deviation became less exo/more eso at distance (p<0.001) but no significant change was found at near (p = 0.069). Stereoacuity, visual acuity, and convergence were found to be reduced in the immediate post-detoxification period. Prism fusion range, refractive error, subjective accommodation, and objective accommodation at 33 cm did not reduce but a small decrease was found in objective accommodation at 20 cm. CONCLUSIONS: The eso trend found in these patients may be responsible for the development of acute concomitant esotropia in some patients undergoing heroin detoxification. However, the mechanism for this trend does not appear to be caused by divergence insufficiency or sixth nerve palsy.

Clinical evaluation and comparison of 2 topical anesthetics for pain caused by needle sticks and scaling and root planing.

BACKGROUND: Pain generated by needle sticks (Ns) for the delivery of local anesthetic and/or scaling and root planing (SRP) instrumentation is commonly addressed by the use of topical anesthetics, such as a benzocaine-gel preparation (BGP). Pain suppression following such use has been highly variable. Development of medicine-containing patches and adhesives for intraoral use have led to a new approach for topical anesthesia in the form of a transoral lidocaine delivery system (LDS). The purpose of this double-blind study was to evaluate the efficacy of the LDS and also to compare LDS with BGP for pain suppression to Ns and SRP. METHODS: One group of 20 subjects randomly received in both maxillary and mandibular molar-bicuspid areas LDS or BGP on one side and non-anesthetic control on the other side. A second group of 20 subjects compared the effectiveness of LDS directly with BGP in molar-bicuspid areas of both arches. Random order determined the selection for each anesthetic tested between the arches and bilateral. Pain perception was separately scored to a pain-inducing Ns simulation without anesthetic injection at each area and subsequently also to SRP using both a verbal pain scale (VPS) and a visual analog scale (VAS). RESULTS: VPS and VAS results analyzed by Bonferroni-adjusted Wilcoxon matched-pairs signed-rank tests found pain suppression scores significantly (P < 0.005) reduced for Ns by LDS to controls and to BGP. Comparing LDS directly with BGP, LDS was significantly (P < 0.05) more effective in reducing pain to Ns in both arches, to SRP in the maxillary arch, and equally effective as BGP in the mandibular arch. CONCLUSIONS: LDS is more effective than BGP for topical pain suppression to Ns and SRP in both arches.

Evaluation of a transoral delivery system for topical anesthesia.

BACKGROUND: The development of bioadhesives has allowed for the creation of a novel transoral topical anesthesia delivery system used to alleviate pain by needlestick injections and select dental procedures. METHODS: Sixty subjects evaluated the effectiveness of a lidocaine-containing bioadhesive patch, or L-BP, to alleviate pain caused by needlesticks, or Ns, with or without injection, and with scaling and root planing, or Sc/RP, instrumentation. The authors topically administered a commonly used benzocaine-containing gel, or B-G, preparation to analogous sites for direct comparison. Subjects rated their degree of pain/discomfort using verbal pain score, or VPS, measurements. RESULTS: Paired t tests and signed ranked tests revealed that the subjects' perception of pain was significantly reduced after the application of L-BP with placebo (P < .01) for both Ns and Sc/RP but was not significantly reduced by B-G with placebo. L-BP also significantly reduced the subjects' perception of pain caused by Ns and Sc/RP when compared directly with B-G (P < .01). The resultant tissue anesthesia by L-BP significantly reduced pain to Ns with or without anesthetic injection using 25- and 27-gauge needles. However, Ns in conjunction with anesthetic injections generated significantly greater pain than that caused by Ns alone (P < .01). VPS score differences between 25- and 27-gauge needles were not found. CONCLUSIONS: This study found that a lidocaine-containing bioadhesive system delivering topical anesthesia was highly effective in alleviating pain/discomfort arising from Ns, with and without concomitant injection, and select Sc/RP procedures. CLINICAL IMPLICATIONS: A new topical delivery system that effectively anesthetizes oral tissues may prove highly useful in allaying patient anxieties about and fear of select dental procedures.

Evaluation of floss types for interproximal plaque removal.

PURPOSE: To evaluate the efficacy of four different floss types for interproximal plaque removal on the normal dentition. MATERIALS AND METHODS: 24 dental hygiene students tested each of four different floss types: waxed, unwaxed, woven and shred-resistant. At baseline, all subjects received a prophylaxis to become plaque-free and identical flossing instructions were given. Subjects were then instructed not to brush, floss, or rinse for 3 days to allow for plaque development. On the fourth day, each subject's teeth were disclosed and scored using O'Leary's Plaque Index. Subjects were then randomly assigned one of the four floss types to use throughout the dentition, following which a second plaque record was assessed. Subjects were timed while flossing, and then completed a 10 cm Visual Analogue Scale (VAS) scoring their degree of discomfort/comfort and ease of use for each specific type of floss. This protocol was followed until all four floss types were tested by each subject. Results analyzed reductions in total interproximal plaque score (TIPS), anterior (teeth) interproximal plaque score (AIPS), and posterior (teeth) interproximal plaque score (PIPS). RESULTS: The greatest reduction in TIPS and PIPS was with waxed floss (68.87%, 66.54% respectively) and in AIPS with woven floss (75.15%). Post-hoc testing using Tukey's method revealed no significant differences among the four floss types. VAS scores revealed shred-resistant most comfortable (6.99) while unwaxed was least (4.29). These results indicated minimal differences in the efficacy of different types of floss, their degree of comfort and ease of use.

A compressed opiate detoxification regime with naltrexone maintenance: patient tolerance, risk assessment and abstinence rates.

Opiate detoxification using methadone programmes are inefficient and expensive. Rapid and ultra-rapid detoxification using precipitated withdrawal under heavy sedation or anaesthesia provide increased efficiency and speed, but are limited by the requirement for high-dependency facilities and are perceived as high-risk procedures. Procedures using precipitated withdrawal over longer periods with lower sedation are safer, but 20% of patients fail to tolerate these. Here we evaluate a naltrexone compressed opiate detoxification (NCOD) protocol. We investigated patient acceptance, organ function and abstinence rates on 504 consecutive patients undergoing treatment at the Harrogate Detox5 centre between February 1996 and January 1999. Ninety-eight per cent of patients completed the procedure; 81% of patients reported withdrawal was "better than expected". Only 3% of patients reported any pain. Laboratory investigations demonstrated no organ dysfunction. Abstinence rates post-detox were high with 71%, 61% and 51% of patients free of opiates 3, 6 and 12 months post-detox, respectively. Compliance with the naltrexone maintenance in abstinent patients was 66%, 68% and 30% at these time points. This NCOD protocol provides an efficient method of detoxifying opiate abusers with little patient discomfort or risk to health. Abstinence rates are better than those in comparable studies using other programmes.

Comparison of the Interplak and manual toothbrushes in a population with mental retardation/developmental disabilities (MR/DD).

A major dental problem confronting persons with mental retardation/developmental disabilities (MR/DD) is poor dental hygiene, which can result in an increased incidence of gingivitis and periodontal disease. Studies indicate that the most obvious reason for the poor oral hygiene of such persons is their inability to clean the oral cavity adequately. The objective of this study was to determine whether there was a difference in the oral health between a group of residents with MR/DD using the Interplak and a group using manual toothbrushes. Fifty-six residents from four Franklin County group homes completed the study. Each group home was divided into two study groups, one using the Interplak and the second using manual toothbrushes. Each subject was seen for initial recording based on the Gingival Index (Löe) and Simplified Oral Hygiene Index (Greene and Vermillion), followed by a thorough prophylaxis. These measurements were recorded again at three, six, and nine months, with a final recording at 12 months. At the conclusion of the study, analysis of the data indicated significant improvement in the Gingival Index over a 12-month period for the residents using the Interplak compared with a manual toothbrush.

A roundtable discussion: hospital leaders discuss QI implementation issues.

To address critical questions regarding the practical application of quality improvement (QI) concepts within health care, the Joint Commission visited six hospitals that have been implementing QI for several years. After the site visits, the leaders of these hospitals participated in a roundtable discussion of QI issues. The discussion centered around nuts-and-bolts topics, such as leadership, implementing QI, barriers/resistances, medical staff involvement, cultural change, institutionalizing QI, and external environment. The roundtable discussion is excerpted in full from a new book, Striving Toward Improvement: Six Hospitals in Search of Quality, which tells the stories of the six hospitals and their transitions to QI.