An integrative review on facilitators and barriers in delivering and managing injectable therapies in chronic conditions: A part of the ACNAP project 'injectable medicines among patients with cardiovascular conditions'.

INTRODUCTION: Although preventive health and therapeutics have benefited from advances in drug development and device innovation, translating these evidence-based treatments into real-world practice remains challenging. AIM: The current integrative review aims to identify facilitators and barriers and perceptions in delivering and managing injectable therapies from patient perspectives. METHODS: An integrative review was conducted in the databases of PubMed, CINAHL, PsycINFO and Cochrane. Keywords were used "Injectable therapy", "IV therapy", "SC therapy", "long term injectable therapies", "self-administered injectable therapy", "patients", "caregivers", "family", "carers", "facilitators", "barriers", "perspectives", "needs", "expectations", "chronic disease", "cardiovascular disease" linked with the words "OR" and "AND". The search was limited from January 2000 to July 2019. Inclusion and exclusion criteria were used. RESULTS: Twenty studies were identified from the literature search. Studies followed qualitative, quantitative methodology and mixed methods. Facilitators included: health improvement, prevention of disease complications, taking control of their disease, effectiveness of the medication and convenience in management. Barriers included: fear of needles, insulin will cause harm, poor perception of the benefits of injectable therapies on their quality of life, inconvenience in self-management, social stigma, impact on daily living, financial barriers, lack of education. Perceptions included: 'treatment of last resort', 'life becomes less flexible', 'injectables were punishment/restriction', 'personal failure of self-management'. CONCLUSION: Evidence shows how to create effective communication and shared decision-making relationships to provide best possible care to patients who need injectable therapy and support for self-management. Future research might help guide response to the fears and barriers of the patients using patients' perspectives.

Warming the postpartum body as a form of postnatal care: An ethnographic study of medical injections and traditional health practices in Cambodia.

Postpartum care is a critical element for ensuring survival and health of mothers and newborns but is often inadequate in low- and middle-income countries due to barriers to access and resource constraints. Newly delivered mothers and their families often rely on traditional forms of postnatal care rooted in social and cultural customs or may blend modern and traditional forms of care. This ethnographic study sought to explore use of biomedical and traditional forms of postnatal care. Data were collected through unstructured observation and in-depth interviews with 15 mothers. Participants reported embracing traditional understandings of health and illness in the post-partum period centered on heating the body through diet, steaming, and other applications of heat, yet also seeking injections from private health care providers. Thematic analysis explored concepts related to transitioning forms of postnatal care, valuing of care through different lenses, and diverse sources of advice on postnatal care. Mothers also described concurrent use of both traditional medicine and biomedical postnatal care, and the importance of adhering to cultural traditions of postnatal care for future health. Maternal and newborn health are closely associated with postnatal care, so ensuring culturally appropriate and high-quality care must be an important priority for stakeholders including understand health practices that are evolving to include injections.

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.

Effect of Topical Anesthesia on Pain from Needle Insertion and Injection and Its Relationship with Anxiety in Patients Awaiting Apical Surgery: A Randomized Double-blind Clinical Trial.

INTRODUCTION: We aimed to simultaneously investigate the effects of topical anesthesia on needle insertion and injection pain in the labial mucosa of the maxillary central incisors of patients awaiting apical surgery and to assess the relationship between patients' anxiety and pain scores. METHODS: Forty-four patients scheduled for apical surgery of the maxillary anterior incisor or canine were included, and all completed the Modified Dental Anxiety Scale (MDAS) questionnaire. One piece of Xylocaine (AstraZeneca, Sodertalje, Sweden) gauze was applied to the right or left side of the labial vestibule below the central incisor according to a randomization process, and 1 piece of water gauze was applied to the contralateral side of the labial vestibule. Each piece of gauze remained in place for 2 minutes. The subjects were asked to rate their pain according to the numeric rating scale immediately after needle insertion and anesthetic solution injection. RESULTS: Topical anesthetic application significantly reduced both insertion- and injection-related pain. Injection pain was significantly higher than insertion pain throughout the experiment. The difference in pain scores between the placebo and topical anesthetic groups was significantly greater for insertion pain than injection pain. The group with higher MDAS scores showed significantly higher pain scores, except for insertion pain reported by the topical anesthetic group, which did not show a significant difference between MDAS score groups. CONCLUSIONS: The topical anesthetic was highly effective for both insertion and injection pain during infiltration anesthesia in the maxillary central incisors. Highly anxious patients reported higher pain scores; however, topical anesthetics reduced the effect of anxiety on increasing pain.

Relationship between Child and Parental Dental Anxiety with Child's Psychological Functioning and Behavior during the Administration of Local Anesthesia.

OBJECTIVES: The aims of this study were to determine: 1) the relationship between children's psychological functioning, dental anxiety and cooperative behavior before and during local anesthesia, 2) the relationship of parental dental anxiety with all the above child characteristics. STUDY DESIGN: There was a convenient sample of 100 children (4-12 years). Child dental anxiety and psychological functioning were measured using the "Children's Fear Survey Schedule" (CFSS-DS) and the "Strengths and Difficulties Questionnaire" (SDQ) respectively. Parental dental anxiety was measured using the "Modified Dental Anxiety Scale" (MDAS). All questionnaires were completed by parents. Before and during local anesthesia, the child behavior was scored by one experienced examiner, using the Venham scale. Non-parametric tests and correlations (Mann-Whitney, Spearman's rho) were used for the analysis. RESULTS: The mean SDQ score was 10±5.6 for boys (n=60) and 8.3±4.8 for girls (n=40) (p=0.038), but there was no correlation with children's age. The mean CFSS-DS score was 33.1±11.86 and there was no correlation with age or gender. Children with higher levels in the pro-social subscale of the SDQ had significantly less anxiety and better behavior before local anesthesia. Higher mean CFSS-DS scores were significantly associated with uncooperative behavior during local anesthesia (p=0.04). There was no correlation between parents' and their children's dental anxiety, psychological functioning and behavior. 46% of the children had previous dental experience in the last 6 months. As time since the last dental treatment increased, an improvement was found in children's behavior during local anesthesia. CONCLUSIONS: Child psychological functioning was related to dental anxiety and behavior during dental appointment involving local anesthesia.

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.

Psychometric properties of the faces version of the Malay-modified child dental anxiety scale.

BACKGROUND: To evaluate the psychometric properties of the faces version of the Modified Child Dental Anxiety Scale (MCDASf) Malay version in 5-6 and 9-12 year-old children. METHODS: The MCDASf was cross culturally adapted from English into Malay. The Malay version was tested for reliability and validity in 3 studies. In the Study 1, to determine test-retest reliability of MCDASf scale, 166 preschool children aged 5-6 years were asked to rank orders five cartoons faces depicting emotions from 'very happy' to 'very sad' faces on two separate occasions 3 weeks apart. A total of 87 other 5-6 year-old children completed the Malay-MCDASf on two separate occasions 3 weeks apart to determine test-retest reliability for Study 2. In study 3, 239 schoolchildren aged 9-12 years completed the Malay-MCDASf and the Malay-Dental Subscale of the Children Fear Survey Schedule (CFSS-DS) at the same sitting to determine the criterion and construct validity. RESULTS: In study 1, Kendall W test showed a high degree of concordance in ranking the cartoon faces picture cards on each of the 2 occasions (time 1, W = 0.955 and time 2, W = 0.954). The Malay-MCDASf demonstrated moderate test-retest reliability (Intraclass correlation coefficient = 0.63, p <0.001) and acceptable internal consistency for all the 6 items (Cronbach's alpha = 0.77) and 8 items (Cronbach's alpha = 0.73). The highest MCDASf scores were observed for the items 'injection in the gum' and 'tooth taken out' for both age groups. The MCDASf significantly correlated with the CFSS-DS (Pearson r = 0.67, p < 0.001). CONCLUSIONS: These psychometric findings support for the inclusion of a cartoon faces rating scale to assess child dental anxiety and the Malay-MCDASf is a reliable and valid measure of dental anxiety in 5-12 year-old children.

Type 1 diabetes stigma in China: a call to end the devaluation of individuals living with a manageable chronic disease.

Stigma is a significant barrier to improving care for individuals with type 1 diabetes mellitus (T1DM). This commentary describes this phenomenon in China, where stigma has led to labeling and devaluing of individuals with T1DM. Difficulties finding a spouse and regulations restricting admission to universities and government employment have forced many individuals to hide their diabetes. The shame, fear, and guilt stemming from stigma may preclude the use of insulin pumps; multiple daily injections, which require pre-meal insulin dosing at school or the workplace; participation in research studies; and general health-seeking behaviors. A multifaceted, multilevel approach is urgently needed and should involve improving public awareness and understanding of T1DM; adoption by health care providers of holistic rather than biomedical approaches to disease management; patient counseling on positive coping skills; and expansion of the scope of research to consider the psychosocial realities of diabetes care in China. Recent media attention in the form of a nationally broadcasted documentary on T1DM is an important step in the right direction. We believe that coordinated action by multiple stakeholders can lead to meaningful improvements in treatment, ultimately leading to better physical and emotional health outcomes for individuals living with this manageable chronic disease.

Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: a prospective study.

Our aim was to analyse the amount of anxiety and fear felt before, immediately after, and one week after, dental extraction. We studied 70 patients (35 men and 35 women (mean (SD) age 43 (±10) years), who were listed for dental extraction under local anaesthesia in a private clinic that specialised in oral surgery. Patients were evaluated on 3 consecutive occasions: immediately preoperatively, immediately postoperatively, and 7 days later. Each patient's anxiety was measured using Spielberger's State-Trait Anxiety Inventory (Spanish version), the Modified Corah Dental Anxiety Scale (MDAS) and the Dental Fear Survey. There were significant differences in the STAI-Trait scale between before and 7 days after extraction (p=0.04), and in the MDAS between before and immediately after extraction (p=0.02), and between immediately after and 7 days after extraction (p=<0.001). The DFS also differed between before and immediately after extraction (p=0.002), and between immediately and 7 days after extraction (p<0.001). Dental anxiety immediately after tooth extraction may be influenced by operative techniques (type of anaesthesia, duration of operation, or position of tooth extracted), but anxiety at 7 days after extraction is not.

Computerized dental injection fear treatment: a randomized clinical trial.

One in four adults reports a clinically significant fear of dental injections, leading many to avoid dental care. While systematic desensitization is the most common therapeutic method for treating specific phobias such as fear of dental injections, lack of access to trained therapists, as well as dentists' lack of training and time in providing such a therapy, means that most fearful individuals are not able to receive the therapy needed to be able to receive necessary dental treatment. Computer Assisted Relaxation Learning (CARL) is a self-paced computerized treatment based on systematic desensitization for dental injection fear. This multicenter, block-randomized, dentist-blind, parallel-group study conducted in 8 sites in the United States compared CARL with an informational pamphlet in reducing fear of dental injections. Participants completing CARL reported significantly greater reduction in self-reported general and injection-specific dental anxiety measures compared with control individuals (p < .001). Twice as many CARL participants (35.3%) as controls (17.6%) opted to receive a dental injection after the intervention, although this was not statistically significant. CARL, therefore, led to significant changes in self-reported fear in study participants, but no significant differences in the proportion of participants having a dental injection.

A novel distraction technique for pain management during local anesthesia administration in pediatric patients.

AIM: The aim of this study was to assess the effect of an active and novel distraction technique WITAUL (Writing In The Air Using Leg) on the pain behavior observed and reported by children receiving local anesthesia injections prior to dental treatment. STUDY DESIGN: The study was conducted on 160 children (80 in control and 80 in intervention group) between the ages of 4- 10 years. During the administration of anesthesia the children in the control group were made to relax by means of deep breathing and those in the intervention group were taught to use the WITAUL distraction technique. the behavior of the children aged 4- 5 years was noted using the Modified Toddler- Preschooler Post operative Pain Scale (TPPPS) and that of children aged above 6 years was measured using the FACES Pain Scale-Revised (FPS-R). RESULTS: The use of WITAUL was found to be statistically significant (p value < 0.0001) compared to the control method in serving as a distraction and hence in managing pain during local anesthesia administration. The mean Modified TPPPS scores (4- 5 year olds) for the WITAL group was 2.46 +/- 1.752 and that of the control was 5.64 +/- 2.328. The mean FPS-R scores (6 - 10 year olds) for the WITAUL group was 3 +/- 1.748 and that of the control group was 6.26 +/- 1.858. CONCLUSION: The WITAUL technique therefore appears to be a simple and effective method of distraction during local anesthesia administration in pediatric patients.

[Blood-injection-injury phobia: Physochophysiological and therapeutical specificities]. / La phobie du sang-injection-accident : spécificités psychophysiologiques et thérapeutiques.

INTRODUCTION: Seventy-five percent of patients with blood-injection-injury phobia (BII-phobia) report a history of fainting in response to phobic stimuli. This specificity may lead to medical conditions remaining undiagnosed and untreated, incurring considerable cost for the individual and society. The psychophysiology of BII-phobia remains poorly understood and the literature on effective treatments has been fairly sparse. Aims of the systematic review: to synthesize the psychophysiology of BII-phobia and to propose a systematic review of the literature on effectiveness of different treatments evaluated in this indication. RESULTS: Firstly, the most distinct feature of the psychophysiology of BII-phobia is its culmination in a vasovagal syncope, which has been described as biphasic. The initial phase involves a sympathetic activation as is typically expected from fear responses of the fight-flight type. The second phase is characterized by a parasympathetic activation leading to fainting, which is associated with disgust. Subjects with syncope related to BII-phobia have an underlying autonomic dysregulation predisposing them to neurally mediated syncope, even in the absence of any blood or injury stimulus. Many studies report that BII-phobic individuals have a higher level of disgust sensitivity than individuals without any phobia. Secondly, behavioral psychotherapy techniques such as exposure only, applied relaxation, applied tension, and tension only, have demonstrated efficacy with no significant difference between all these techniques. The disgust induction has not improved effectiveness of exposure. CONCLUSION: We have explained the psychophysiology of BII-phobia, the understanding of which is required to study and validate specific techniques, in order to improve the prognosis of this disorder, which is a public health issue.

Preattentive processing of feared stimuli in blood-injection-injury fearful subjects.

This research aimed to study the defence responses of blood-injection-injury (BII) fearful subjects elicited by the preattentive processing of their feared objects and by an abrupt acoustic stimulus. We selected 21 BII fearful subjects and 25 non-fearful controls from an initial sample of 128 women, according to their scores on the Fear Survey Scale (damage subscale) and the Mutilation Questionnaire. Subjects were exposed to a burst of white noise to promote a defence response, and to 48 pictures, depicting mutilations, as well as other affective contents, displayed through a backward masking procedure. Heart rate (HR), skin conductance response (SCR) and corrugator supercilii activity were continuously recorded throughout the task. Both groups showed similar SCRs, EMG activity and cardiac defence responses to the acoustic stimulus, though fearful subjects showed greater initial HR deceleration than controls. While BII fearful subjects displayed the usual defence response when exposed to a non-feared threatening stimulus, the preattentive processing of the pictures did not reveal autonomic differences between fearful subjects and controls. Mutilation pictures, however, evoked the greatest EMG activity, but only in the fearful group. These data further extend previous research on conscious perception of blood-related stimuli in BII fearful subjects, by showing a failure to recruit autonomic defence responses when blood-related pictures appear outside of conscious awareness.

A clinician guide to patients afraid of dental injections and numbness.

Fears of dental injections remain a clinical problem often requiring cognitive behavioural psychology counselling and sedation in order to carry out needed dental treatment. This study, based on a national survey in Australia, compared patient concerns about numbness caused by local anaesthesia and fears of the injection itself. It also examined associations between dental fearfulness and avoidance associated with patient self-reported negative experiences and treatment need. Clinical advice on how to approach such patients is offered. Relatively high levels of dental anxiety and fear have been reported in several industrialised Western societies (McGrath & Bedi, 2004; Armfield, Spencer & Stewart, 2006; Lahti et al., 2007; Enkling, Marwinski Jöhren, 2006). In the U.K., almost one in three adults consider themselves to always be anxious about going to the dentist (Nuttall et al., 2001). Of concern is that this dental fear may be passed on to the children of anxious adults (Nuttall, Gilbert & Morris, 2008), leading to an inter-generational perpetuation of the problem. There is considerable evidence that dental fear is related to poorer oral health, reduced dental attendance and increased treatment stress for the attending dentist. There are many aspects of going to a dentist that might elicit feelings of apprehension, concern or anxiety in prospective patients (Liddell & Gosse, 1998; Oosterink, de Jongh & Aartman, 2008). One of the most commonly reported concerns relates to receiving injections. Indeed, fear of needles and the treatment of injection fear has been an important focus of a research in the U.K. (Boyle, Newton & Milgrom, 2010). Needle fear, in particular, is a major issue given that the delivery of local anaesthesia via injection is the central plank of pain relief techniques in dentistry (Malamed, 2009) and dentists as well as patients often avoid difficult injections as a consequence, resulting in poor pain control. A less well described anxiety of receiving dental treatment is fear of numbness associated with the dental injection (Morse & Cohen, 1983). Certainly, many dentists believe that their patients avoid local anaesthesia because of a wish to avoid the disturbing effects of numbness (Moore et al., 1998). Milgrom et al. (1997) found that fears about the numbness associated with receiving local anaesthesia significantly differentiated avoiders and non-avoiders of dental treatment. However, these concerns appeared to be much less common than those concerning the perceived pain of injections and fear of bodily injury resulting from the injection (Milgrom et al., 1997; Kaako et al., 1998). Consistent with these findings, whereas 43% of English patients asked to imagine undergoing future third molar surgery expressed concerns primarily about pain, only 6% of patients indicated concern about numbness as their worst fear (Earl, 1994). More recently, a study of Dutch people found that the feeling of numbness from the anaesthesia was rated as the 41st most feared dental stimulus out of a list of 67 possible stimuli, and that only 1.5% of the general population regarded numbness as extremely anxiety provoking (Oosterink, de Jongh & Aartman, 2008). However, it is important for a clinician to differentiate between those who dislike the sensation of temporary numbness versus those who may worry that it may never wear off. Such problem thinking can be an issue irrespective of whether a patient overcomes the fear of needles with sedation or not. A large number of patients dislike the sensation of numbness enough for manufacturers to respond with a partial antidote in alpha adrenergic receptor antagonist phentolamine mesylate (OraVerse Sanofi-Aventis, Hersh & Lindemeyer, 2010). Approval of this agent, which shortens the length of soft tissue anaesthesia after inferior alveolar block, is pending in the UK and other European countries. In other cases, dentists resort to using local anaesthetics without vasoconstrictors to shorten the period of anaesthesia (Fiset, Getz, Milgrom & Weinstein, 1989). While the association between dental fear and fear of injections has received considerable attention, the relationship between dental fear and numbness has received less attention. In particular, the nature of the associations between dental fear and avoidance and anxiety over numbness has not been studied. There has also been no research into whether or not concerns over numbness are independent of injection concerns. Finally, the association between fear of numbness and injections and dental avoidance and treatment needs has not been investigated. This study, based on survey work in Australia, aimed to compare patient concerns about numbness caused by receiving anaesthesia to that of anxiety over the receipt of needles and injections. Associations with dental fear and avoidance as well as negative experiences and treatment needs were also explored.

The functional neuroanatomy of blood-injection-injury phobia: a comparison with spider phobics and healthy controls.

BACKGROUND: Most neuroimaging studies of specific phobia have investigated the animal subtype. The blood-injection-injury (BII) subtype is characterized by a unique biphasic psychophysiological response, which could suggest a distinct neural substrate, but direct comparisons between phobia types are lacking. METHOD: This study compared the neural responses during the presentation of phobia-specific stimuli in 12 BII phobics, 14 spider (SP) phobics and 14 healthy controls using functional magnetic resonance imaging (fMRI). RESULTS: Subjective ratings showed that the experimental paradigm produced the desired symptom-specific effects. As in many previous studies, when viewing spider-related stimuli, SP phobics showed increased activation in dorsal anterior cingulate and anterior insula, compared to BII phobics and healthy controls. However, when viewing images of blood-injection-injuries, participants with BII phobia mainly showed increased activation in the thalamus and visual/attention areas (occipito-temporo-parietal cortex), compared with the other two groups. The degree of provoked anxiety and disgust by phobia-relevant images was strongly associated with activation in several common regions across the two phobia groups (thalamus, cerebellum, occipito-temporal regions) but only correlated with activation in the dorsal anterior cingulate gyrus and the anterior insula in the SP phobics. CONCLUSIONS: These results suggest partially distinct neurobiological substrates of animal and BII phobias and support their current classification as two distinct subtypes in the DSM-IV-TR. Further research is needed to better understand the precise neurobiological mechanisms in BII phobia and particularly the fainting response.

[Fear of dental treatment among children. Influence of experience and psychological functioning]. / Angst voor een tandheelkundige behandeling bij kinderen. Invloed van ervaring en psychisch functioneren.

This research considers whether fear of dental treatment among children is linked with a prior (negative) experience with local anaesthesia or with psychological functioning. Furthermore, the study investigated whether these factors play a role in anxious behaviour before and during a local anaesthetic injection. In this study 128 children between the ages of 4 and 11 took part. With the help of video recordings, the anxious behaviour before and during the local anaesthetic injection was scored using the Venham-scale. During the treatment one of the child's parents or guardians was asked if the child had previously been given a local anaesthetic injection (experience). The fear of dental treatment and the child's psychological functioning were measured using the parents' version of the 'Dental Subscale' of the 'Children's Fear Survey Schedule' and the 'Strengths and Difficulties Questionnaire' respectively. Results showed a correlation between on one hand fear of dental treatment and on the other hand anxious behaviour before and during a local anaesthetic injection and psychological functioning. Furthermore, results indicated that children with fear of dental treatment exhibited more fearful behaviour before and during an injection with local anaesthetic. Only in the case of children whose psychological functioning was reduced there was a significant relationship between experience with local anaesthesia and fearful behaviour prior to the injection of a local anaesthetic.

Dental anxiety and psychological functioning in children: its relationship with behaviour during treatment.

AIM: In this study the relationship between the levels of dental anxiety, psychological functioning and earlier experience with dental injections are examined and the possible influence of these factors on children's behaviour before and during a local anaesthesia injection. METHODS: A total of 128 children (4-11 years) were included. The level of dental anxiety and the psychological functioning were measured using the 'Children's Fear Survey Schedule' (CFSS-DS) and the 'Strengths and Difficulties Questionnaire' (SDQ). Based on video recordings the anxiety behaviour was scored on the Venham-scale. RESULTS: There was a positive correlation between levels of dental anxiety, psychological functioning and anxiety behaviour before and during the dental injection. In particular children with emotional problems or peer problems tended to show more anxiety behaviour before the injection and children with emotional or hyperactivity problems tend to show more anxiety behaviour during the injection. Furthermore, the younger children (below 6 years of age), with previous dental experience in the past 6 months, tended to display more anxiety behaviour both before and during the injection than children without or with experience from longer ago. CONCLUSION: The level of dental anxiety and psychological functioning and recent previous dental experience are important factors in determining which child is likely to display more anxiety and uncooperative behaviour during treatment and therefore potentially need more attention to be able to cope well with dental treatment.

Pain behaviour and distress in children during two sequential dental visits: comparing a computerised anaesthesia delivery system and a traditional syringe.

OBJECTIVE: To compare the pain and distress response of children receiving a local anesthesia injection using a computerised device (Wand) or a traditional syringe over two consecutive treatment sessions and to study whether the response to the two injection techniques was different for high or low dentally anxious children. DESIGN: Randomised controlled trial. SETTING: Secondary dental care practice specialised in treating children. SUBJECTS AND METHODS: Children were selected and randomly allocated to the Wand or traditional injection condition. Parents completed the Dental Subscale of the Children's Fear Survey Schedule (CFSS-ds). Based on video recordings of the injections, for each 15 seconds, the occurrence of five pain related behaviours was registered and a score was given on the Venham distress scale. Children rated their pain after each injection. INTERVENTION: Over two consecutive treatment sessions one group received two local anaesthesia injections with the traditional syringe and the other group received two injections with the Wand. OUTCOME MEASURES: The mean number of pain related behaviours, the mean distress scores and the self-reported pain scores were compared. Based on the CFSS-ds subjects were split into highly and low dentally anxious children. RESULTS: One hundred and forty-seven subjects participated in the study: aged 4-11 years, 71 girls. Based on the behaviour displayed during the local anaesthesia injection and the self-reported pain after the injection, no difference could be found between an injection with the traditional syringe or the Wand over the first or second treatment session. However, on the first treatment session, highly anxious children reported more pain (p = 0.001), displayed more pain related behaviour (p = 0.002) and more distress (p <0.001) than low anxious children in reaction to the local anaesthesia injection. CONCLUSION: No clear difference in the response of referred children could be found between an injection with the Wand or the traditional syringe. Level of dental anxiety was found to be an important factor in the response of children to a local anaesthesia injection.

Combining alprazolam with systematic desensitization therapy for dental injection phobia.

To determine whether a benzodiazepine facilitates systematic desensitization, 144 subjects with dental injection phobia received systematic desensitization in combination with placebo or one of two doses of alprazolam (0.5mg or 0.75mg). Systematic desensitization therapy included computer-controlled presentation of digitized video segments followed by in vivo exposure segments, culminating in an actual dental injection. Subjects advanced to the next hierarchy segment when low anxiety was reported during a segment. Alprazolam and placebo groups progressed at the same rate. The 0.75mg group had elevated heart rates while watching video segments compared with placebo. In a subsequent behavioral avoidance test (during which subjects were randomized to a new drug condition), there was no indication that state-dependent learning had occurred. Dental fear was reduced similarly in all groups for 1 year after study completion. No advantage was found to combining alprazolam with systematic desensitization for dental injection phobia.