Effectiveness of standardized ultrasound guided percutaneous treatment of lateral epicondylitis with application of autologous blood, dextrose or perforation only on pain: a study protocol for a multi-center, blinded, randomized controlled trial with a 1 year follow up.

BACKGROUND: In the treatment of Lateral Epicondylitis (LE) no single intervention concerning injection therapies has been proven to be the most effective with regard to pain reduction. In this trial 3 injection therapies (perforation with application of autologous blood, perforation with application of dextrose and perforation only) will be compared in a standardized and ultrasound guided way. The objective is to assess the effectiveness of these 3 injection therapies on pain, quality of life and functional recovery. By conducting this study, we hope to make a statement on the effectiveness of injection therapy in the treatment of LE. Hereby, unnecessary treatments can be avoided, a more universal method of treatment can be established and the quality of the treatment can be improved. METHODS/DESIGN: A multicenter, randomized controlled trial with a superiority design and 12 months follow-up will be conducted in four Dutch hospitals. One hundred sixty five patients will be recruited in the age of 18 to 65 years, with chronic symptomatic lateral epicondylitis lasting longer than 6 weeks, which have concordant pain during physical examination. Patients will be randomized by block randomization to one of the three treatment arms. The treatment will be blinded for patients and outcome assessors. The following three injection therapies are compared: perforation with application of autologous blood, perforation with application of dextrose and perforation only. Injections will be performed ultrasound guided in a standardized and automated way. The primary endpoint is: pain (change in 'Visual Analogue Scale'). Secondary endpoints are quality of life and functional recovery. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment. DISCUSSION: When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. In current literature proper comparison of the effectiveness of injectables for LE is questionable, due to the lack of standardization of the treatment. This study will overcome bias due to manually performed injection therapy. TRIAL REGISTRATION: This study is registered in the Trial Register ( www.trialregister.nl ) of the Dutch Cochrane centre. Trial ID; NTR4569. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4569.

Racial Differences in Perceptions of Psoriasis Therapies: Implications for Racial Disparities in Psoriasis Treatment.

In the United States, black patients are less likely than white patients to receive biologic treatment for their psoriasis. We conducted a qualitative free-listing study to identify patient-generated factors that may explain this apparent racial disparity in psoriasis treatment by comparing the perceptions of biologics and other psoriasis therapies between white and black adults with psoriasis. Participants included 68 white and black adults with moderate to severe psoriasis who had and had not received biologic treatment. Each participant was asked to list words in response to verbal probes querying five psoriasis treatments: self-injectable biologics, infliximab, methotrexate, apremilast, and phototherapy. Salience scores indicating the relative importance of each word were calculated, and salient words were compared across each race/treatment group. Participants who had experience with biologics generally associated positive words with self-injectable biologics. Among biologic-naïve participants, "apprehension," "side effects," and "immune suppression" were most salient. "Unfamiliar" and "dislike needles" were salient only among black participants who were biologic naïve. Participants were generally unfamiliar with the other psoriasis therapies except phototherapy. Unfamiliarity with biologics, particularly among black, biologic-naïve patients, may partly explain the existing racial disparity in biologic treatment for psoriasis and might stem from lack of exposure to or poor understanding of biologics.

Latex hypersensitivity to injection devices for biologic therapies in psoriasis patients.

An allergic reaction provoked by reexposure to an allergen or antigen is known as a type I or immediate hypersensitivity reaction. Latex allergy is a common cause of type I hypersensitivity reactions. Allergic responses to latex in psoriasis patients receiving frequent injections with biologic agents are not commonly reported in the literature. We report the case of a patient with a long history of psoriasis who developed an allergic response after exposure to injection devices that contained latex components while undergoing treatment with biologic agents.

Globalization and anaphylaxis.

PURPOSE OF REVIEW: To understand the impact of globalization in the management of anaphylaxis and identify potential strategies to improve patients' care and prevention. RECENT FINDINGS: Developments in the field of anaphylaxis have been consistently following these globalization trends offering possibilities of collaborations of the allergy community and integrated international initiatives to reach quality care of allergic patients worldwide. SUMMARY: Globalization is the process of interaction and integration between people, companies, and governments worldwide. Developments in the field of anaphylaxis have been following these globalization trends offering possibilities of collaborations and integrated international initiatives to reach quality care of allergic patients worldwide. Complex disorders, such as anaphylaxis, have called for complex integrative strategies, leading to a new acceptance of outside traditions. Allergy is encouraging us to accept holistic and integrative medical practices as viable options. With the dissolution of multinational boundaries and the universal free access to information, the notion of holistic and global-based care is emerging as the new reality of the medicine. We strongly believe that the integrated action plan to the management and prevention of anaphylaxis, just possible through the globalization, is a key health, political and economical move that advocates for the best practice of allergology.

Effects of a Training Needle on Dental Hygiene Student Anxiety.

Purpose: The purpose of this pilot study was to assess whether practicing with a cotton-tipped applicator as compared to a new training device had an effect on the anxiety levels of dental hygiene students prior to administering and receiving their first intraoral injection for local anesthesia.Methods: This pilot study used a convenience sample of senior dental hygiene students from an entry-level Bachelor degree dental hygiene program. Participants completed a pre-test survey after watching a video demonstrating the inferior alveolar nerve block (IANB) injection technique to determine anxiety levels regarding administering and receiving an intraoral injection. Test and control groups were randomly assigned; and participants either received a dental syringe with an attached training needle device (test) or a cotton tip applicator (control). Both groups completed a post-test survey following a 15 minute practice session. Descriptive statistics were performed and Chi-square tests were used to determine significance.Results: Pre-test results showed that 91% of the participants (n=23) reported having anxiety regarding administering or receiving an intraoral injection in one or multiple areas. Chi-square tests determined no statistical significance (p =0.125) between the test and control groups in the post-test surveys.Conclusion: Dental hygiene students demonstrated decreased anxiety levels regarding administering and receiving an intraoral injection regardless of the assigned practice device in this pilot study. While use of a training needle was not shown to be superior at reducing anxiety in novice student operators when compared to a cotton tipped applicator, it may be a useful device for teaching local anesthesia administration techniques.

Single tooth anaesthesia: a new approach to the paediatric patient. A clinical experimental study.

AIM: The objective of this study is to assess the efficacy of the STA Wand System with respect to pain and fear reduction in paediatric patients and by using the Single Tooth Anaesthesia (STA) technique. MATERIALS AND METHODS: Patients included children and teenagers between 6 and 17 years of age, who required the administration of local anaesthesia prior to expected treatments. Local anaesthesia was performed by means of the electronic STA Wand System (Milestone scientific., Inc.) adopting the Single Tooth Anaesthesia (STA) technique. Pre- and post-anaesthesia, the patients were asked to complete the Wong-Baker faces image scale and the provider filled in the Frankl Scale. RESULTS: All treatments were completed successfully and no collaboration issues were recorded. Frankl's assessment showed that 91% of patients regarded dental experience positively. The efficacy of the computer-assisted anaesthesia was at 100% when treating primary teeth, and 70% for procedures on permanent teeth. Almost the totality of treated patients (94%) gave a positive evaluation after having tried the device with STA technique. Only 6% of the patients assessed the procedure negatively. CONCLUSIONS: The STA technique allows for absence of anticipatory anxiety, absence of physical pain, no anaesthetic effects in the perioral tissues and a controllable, lower dosage of the anaesthetic liquid.

Single tooth anesthesia versus conventional anesthesia: a cross-over study.

OBJECTIVES: The aim of the present study was to compare an electronic device, the Wand Injection System (Milestone Scientific Livingstone), with conventional anesthesia in terms of the following: pain sensation during anesthetic injection; effectiveness in achieving adequate anesthesia for a complete painless dental treatment; post-operative discomfort; and patient's anxiety toward dental treatment. MATERIALS AND METHODS: Eighty adults from 18 to 70 years were enrolled in this cross-over study. Each patient served as his/her own control being subject to two anesthesia techniques: conventional and Single Tooth Anesthesia (STA) performed with the Wand. A split-mouth design was adopted in which each tooth undergoing conservative restorative or endodontic treatment received anesthesia with both techniques at 1-week interval. Before anesthetic administration, the patients' anxiety levels were determined. Physiological parameteres were measured before, during, and after the two injection procedures, and the Visual Analogue Scale (VAS) was used to assess pain of injection, discomfort, and anesthetic efficacy. Differences in assessment of pain's injection, discomfort, anesthetic efficacy, vital parameters (heart rate, blood pressure, and oxygen saturation), and state anxiety levels were analyzed using Student's t test (p value < 0.001). RESULTS: The mean injection pain and post-operative discomfort ratings with Wand were lower than those with conventional syringe (p = 0.022 and p < 0.001, respectively). No differences were found in the assessment of anesthetic efficacy. Blood pressure and heart rate mean values were lower during the anesthesia performed with the Wand than with the conventional syringe (p < 0.001). The anxiety level was higher during the first appointment, independently from the device used for the injections. CONCLUSION: The STA technique resulted in lower pain, discomfort, and lower intensity of physiological parameters. CLINICAL RELEVANCE: Single Tooth Anesthesia could be an efficacious alternative to conventional procedures.

A Vibration Device to Control Injection Discomfort.

Pain from local anesthesia injections can be reduced by distraction and counter-stimulation techniques. This study investigated the DentalVibe® Injection Comfort System (third-generation, DV3), developed to lessen anesthesia pain through pulsed vibration, a form of counter-stimulation. The aim of the study was to evaluate both the efficacy of DV3 in reducing pain and discomfort from intraoral long buccal (LB) and inferior alveolar nerve (IAN) injections and the time needed to achieve complete anesthesia during an IAN block. The study enrolled 60 subjects, 30 men and 30 women, aged 21 to 32 years, who rated both injection pain on a visual analog scale and discomfort, unpleasantness, and difficulty in enduring the injection on a modified symptom severity index. Each subject received bilateral LB injections and an IAN block. Using block design, the third-generation DV (DV3) was randomly assigned to either the first or second LB injection and to 30 subjects on their third injection, the IAN block. No topical anesthesia was applied. Subjects receiving DV3 reported significantly less pain, discomfort, unpleasantness, and difficulty in enduring LB and IAN injections (P < .05), regardless of whether DV3 was used on the first or second LB injection. Time to complete anesthesia was not significantly different (P > .05) when DV3 was used on IAN block injections. The DV3 significantly (P < .02) reduced pain/discomfort from anesthetic injections in this pilot study, in which many subjects were either dental or medical students familiar with performing and enduring injections. More studies are warranted on layperson populations.

Intraligamentary and Supraperiosteal Anesthesia Efficacy Using a Computer Controlled Delivery System in Mandibular Molars.

PURPOSE: The purpose of this study was to compare pain, efficacy and postoperative complications of anesthesia in first primary mandibular molars anesthetized with either intraligamentary (IL) or supraperiosteal (SP) anesthesia using a computer-controlled delivery system (CCDS). STUDY DESIGN: This randomized, controlled-crossover, blind clinical trial was conducted with 90 children requiring bilateral extraction, pulpotomy or restorative treatment of first mandibular primary molars. A CCDS was used to deliver IL anesthesia to 1 deciduous tooth and SP anesthesia to the contralateral tooth in each patient. Severity of pain and efficacy of anesthesia during the treatments were evaluated using the Wong-Baker Faces Pain Rating Scale (PRS) and comfort and side effects were assessed using post-injection and post-treatment questionnaires. Data were analyzed using χ2 and Mann-Whitney U tests. RESULTS: According to PRS scores, pain levels during extraction were significantly higher with IL when compared to SP. Patients reported significantly less pain during needle insertion with SP when compared to IL; however, rates of postoperative complications were significantly higher with SP when compared to IL. CONCLUSIONS: CCDS-administered IL anesthesia and SP anesthesia were similarly effective when used during restorative treatment and pulpotomy of primary mandibular molars; however, SP was more effective than IL when used during extraction procedures.

A randomized split-mouth clinical trial comparing pain experienced during palatal injections with traditional syringe versus controlled-flow delivery Calaject technique.

OBJECTIVE: To compare the pain experienced by patients during injections of local anesthesia in the palate using the traditional syringe and the controlled flow technique with the Calaject system. METHOD AND MATERIALS: A single-blind, split-mouth, randomized controlled trial was performed. Twenty-five volunteers were recruited in the Dental Hospital of the University of Barcelona, Spain. Each participant received two injections (0.3 mL of mepivacaine 3%), one with the traditional syringe (control side) and another with the Calaject system (experimental side), both during the same session. Pain intensity was evaluated after each injection with a 100-mm visual analog scale (VAS). A descriptive and bivariate statistical analysis was made. RESULTS: The mean pain experienced was 44.8 mm (standard deviation [SD] 19.0, range 8-72) with the traditional injection and 28.8 mm (SD 19.7, range 8-72) with the Calaject system (P < .001). Moderate/severe pain was more frequently referred in the control side (68%) in comparison with the experimental side (28%). CONCLUSION: Given the parameters of this study's design, the injection of local anesthetics in the palatal area with the Calaject controlled-flow system seems to reduce pain, in comparison to the use of a traditional syringe.

Evaluation of the injection pain with the use of DentalVibe injection system during supraperiosteal anaesthesia in children: a randomised clinical trial.

PURPOSE: The purpose of this study was to compare the use of a traditional syringe (TS) and the DentalVibe (DV) Injection Comfort System on the pain of needle insertion and injection of supraperiosteal (SP) anaesthesia into the mandibles and maxillas of children aged 6-12 years. METHODS: The study was a randomised, controlled, crossover clinical trial, comprising 60 children requiring an operative procedure with SP anaesthesia on both their mandibular and maxillary molars, bilaterally. One of the molars was treated with a TS, and the contralateral tooth was treated with the DV for both arches. On each visit, subjective and objective pain was evaluated using the Wong-Baker FACES Pain Rating Scale and the Face, Leg, Activity, Cry, Consolability Scale. Patients were asked which technique they preferred. The data were analysed using Wilcoxon signed-rank test, Spearman's correlation test, and Mann-Whitney U-test. RESULTS: No statistically significant differences were noted between TS and DV for pain during injection and needle insertion for supraperiosteal anaesthesia in either the maxillary and mandibular operative procedures. CONCLUSIONS: Children experienced similar pain during SP anaesthesia administered with a TS and the DV, regardless of gender and jaw differences. DV was less preferred over the traditional procedure in children.

New perineal injection technique for pudendal nerve infiltration in diagnostic and therapeutic procedures.

PURPOSE: Pudendal nerve injection is used as a diagnostic procedure in the vulvar region and for therapeutic purposes, such as in vulvodynia. Here, we provide a new, easy-to-perform perineal injection technique. PATIENTS AND METHODS: We analyzed 105 perineal injections into the pudendal nerve with a local anesthetic (LA), procaine in 20 patients. A 0.4 × 40 mm needle was handled using a stop-and-go technique while monitoring the patient's discomfort. The needle was placed 1-2 cm laterally to the dorsal introitus. After aspiration, a small amount of LA was applied. After subcutaneous anesthesia, the needle was further advanced step-by-step. Thus, 5 ml could be applied with little discomfort to the patient. Anesthesia in the pudendal target region was the primary endpoint of our analysis. RESULTS: In 93 of 105 injections (88.6 %), complete perineal anesthesia was achieved with a single injection. 12 injections were repeated. These injections were excluded from the analysis. Severity of injection pain, on visual analog scale (VAS) from 0 to 100, was 26.8 (95 % CI 7.2-46.4). Age (ß = 0.33, p < 0.01) and the number of previous injections (ß = 0.35, p < 0.01) inversely correlated with injection pain. Injection pain and anesthesia were not affected by BMI, the number and the side of previous injections, or order of injection. A reversible vasovagal reaction was common, but no serious adverse effects occurred. CONCLUSION: Perineal pudendal injection is an effective and safe technique for anesthesia in diagnostic (vulva biopsy) and therapeutic indications (pudendal neuralgia), and regional anesthesia in perinatal settings.

Pain Perception: Computerized versus Traditional Local Anesthesia in Pediatric Patients.

BACKGROUND: Local anesthetic injection is one of the most anxiety- provoking procedure for both children and adult patients in dentistry. A computerized system for slow delivery of local anesthetic has been developed as a possible solution to reduce the pain related to the local anesthetic injection. STUDY DESIGN: The present study was conducted to evaluate and compare pain perception rates in pediatric patients with computerized system and traditional methods, both objectively and subjectively. STUDY DESIGN: It was a randomized controlled study in one hundred children aged 8-12 years in healthy physical and mental state, assessed as being cooperative, requiring extraction of maxillary primary molars. Children were divided into two groups by random sampling - Group A received buccal and palatal infiltration injection using Wand, while Group B received buccal and palatal infiltration using traditional syringe. Visual Analog scale (VAS) was used for subjective evaluation of pain perception by patient. Sound, Eye, Motor (SEM) scale was used as an objective method where sound, eye and motor reactions of patient were observed and heart rate measurement using pulse oximeter was used as the physiological parameter for objective evaluation. RESULTS: Patients experienced significantly less pain of injection with the computerized method during palatal infiltration, while less pain was not statistically significant during buccal infiltration. Heart rate increased during both buccal and palatal infiltration in traditional and computerized local anesthesia, but difference between traditional and computerized method was not statistically significant. CONCLUSION: It was concluded that pain perception was significantly more during traditional palatal infiltration injection as compared to computerized palatal infiltration, while there was no difference in pain perception during buccal infiltration in both the groups.

Intraosseous anaesthesia in children with 4 % articaine and epinephrine 1:400,000 using computer-assisted systems.

AIM: To assess retrospectively the efficacy of computer-assisted intraosseous anaesthesia (CAIO) in children using an anaesthetic solution with a lower concentration of epinephrine (1:400,000). METHODS: In a retrospective study, CAIO was evaluated in healthy children and adolescents for restorative and endodontic treatments, uncomplicated tooth extractions or scalings using articaine 4 % plus epinephrine 1:400,000. Anaesthesia was performed in children who showed enough compliance (score of 0-3 according to modified behaviour Venham scale). Efficacy, amount of anaesthetic solution as well as need of a complementary injection was assessed. RESULTS: A total of 421 consecutive sessions were performed on 278 patients aged 7.1 ± 2.9 years with 518 teeth involved in the anaesthetic process and analysed process. When teeth to be anaesthetised were considered, the overall success rate was 97.2 %. In most of the cases, only 0.9 mL was needed to achieve anaesthesia. Permanent teeth needed significantly more anaesthetics than primary teeth. Sensitivity of the teeth anaesthetized reappeared in 5.7 % of cases after 30-60 min of treatment. CONCLUSIONS: These results suggest that CAIO with 4 % articaine and epinephrine diluted 1:400,000 can be an alternative to usual infiltration techniques or IO with epinephrine at a higher concentration for most of treatments in primary and permanent teeth. Further studies are needed to evaluate its efficacy in permanent teeth in case of endodontic treatment or extraction.

A clinical guide to needle desensitization for the paediatric patient.

Needle phobia is a common problem encountered by dental practitioners and it can pose a challenge, especially in the paediatric patient. Needle desensitization can be used for patients who have needle fear or phobia and help them overcome this by repeated, non-threatening and controlled contacts. This paper will describe an accepted technique of needle desensitization and work through the steps required to achieve a successful outcome of local anaesthesia being delivered in a calm, safe and controlled manner. Clinical Relevance: Needle desensitization is an effective technique which can be used to enable a needle phobic patient to receive a dental injection.

Computer-assisted intraosseous anaesthesia for molar and incisor hypomineralisation teeth. A preliminary study.

Anesthetizing MIH (Molar and Incisor Hypomineralisation) teeth is one of the major challenges in paediatric dentistry. Computer-assisted IO injection (CAIO) of 4% articaine with 1:200,000 epinephrine (Alphacaine, Septodont) has been shown to be an efficient way to anesthetize teeth in children. The aim of this study was to assess the efficacy of this method with MIH teeth. This preliminary study was performed using the Quick Sleeper system (Dental Hi Tec, Cholet, France) that allows computer-controlled rotation of the needle to penetrate the bone and computer-controlled injection of the anaesthetic solution. Patients (39) of the department of Paediatric Dentistry were included allowing 46 sessions (including 32 mandibular first permanent molars) to be assessed. CAIO showed efficacy in 93.5% (43/46) of cases. Failures (3) were due to impossibility to reach the spongy bone (1) and to achieve anaesthesia (2). This prospective study confirms that CAIO anaesthesia is a promising method to anesthetize teeth with MIH that could therefore be routinely used by trained practitioners.

Ophthalmologic complications after intraoral local anesthesia.

INTRODUCTION: The first ophthalmologic complication in conjunction with a dental anesthesia was reported in 1936. The objective of the present study was a detailed analysis of case reports about that topic. MATERIAL AND METHODS: After conducting a literature search in PubMed this study analyzed 108 ophthalmologic complications following intraoral local anesthesia in 65 case reports with respect to patient-, anesthesia-, and complication- related factors. RESULTS: The mean age of the patients was 33.8 years and females predominated (72.3%). The most commonly reported complication was diplopia (39.8%), mostly resulting from paralysis of the lateral rectus muscle. Other relatively frequent complications included ptosis (16.7%), mydriasis (14.8%) and amaurosis (13%). Ophthalmologic complications were mainly associated with block anesthesia of the inferior alveolar nerve (45.8%) or the posterior superior alveolar nerve (40.3%). Typically, the ophthalmologic complications in conjunction with intraoral local anesthesia had an immediate to short onset, and disappeared as the anesthesia subsided. DISCUSSION AND CONCLUSION: The increased number of ophthalmologic complications after intraoral local anesthesia in females may suggest a gender effect. Double vision (diplopia) is the most frequently described complication, which is usually completely reversible like the other reported ophthalmologic complications.

An ex vivo comparison of pressures within dental pulp space using conventional anesthetic technique versus needle-mounted obturator.

INTRODUCTION: The intrapulpal (IP) injection technique is 1 of several ways of obtaining profound anesthesia. There is evidence to suggest that pressure is the primary factor in obtaining anesthesia using IP injection. This is an ex vivo comparison of pressures within dental pulp space using the conventional anesthetic technique versus a needle-mounted obturator technique. METHODS: Twenty extracted anterior and premolar teeth were accessed with a high-speed 169L bur. A saline-filled tube connected to a digital pressure gauge was attached to the apical 10 mm of each tooth in a fixed mount. One operator performed all the injections under moderate pressure. Each tooth was injected twice; first, the tooth was given an IP injection with a normal setup, and then the same tooth was given an IP injection with the modified obturator syringe. The pressure at the apex was recorded for each tooth. A paired sample t test was completed to determine statistical significance. RESULTS: The pressure generated was considerably higher for the obturator group in every tooth when compared with the normal group (P < .001). CONCLUSIONS: IP injection with the obturator resulted in increased pressure at the apex of each tooth. This pressure increase may allow for increased anesthesia when IP injections are indicated.