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Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years
J Oral Maxillofac Surg 53:971-976, 1995
Abstracts Cranial Bone Grafting in Children. Koenig W J, Donovan M, Pendsler JM. Plast Reconstr Surg 95:1, 1995
When a larger strip such as a 3-mm width is inserted, the Gore-Tex is threaded into the opening of a 12-gauge angiocath and is fastened with a suture. The angiocath is then pulled backward, leaving the Gore-Tex in the proper position. No sutures are needed to close either entrance or exit sites of the angiocath. In patients who lack philtral crest height, two small pieces can be introduced in a similar fashion into the philtrum. Patients were noted to regain a socially acceptable appearance within 1 week. The postoperative discomfort and swelling was considered minimal. The authors prefer this method over others for correction of the thinned and ptotic lip in patients who desire a more esthetically pleasing lip complex.--K.N. CHow
Cranial bone is often the graft of choice in craniofacial reconstruction because of its favorable survival, location, and minimal donor site morbidity. The purpose of this study was to evaluate cranial bone thickness in the parietal bone as it relates to age and to assess the presence or absence of a diploic space. Computed tomography (CT) scans of 96 patients between newborn and 21 years of age were examined. The thickness of the parietal bone was measured at a point two thirds the distance from the external auditory meatus and the sagittal suture on both sides, and averaged. Presence or absence of a diploic space were also recorded. Five patients undergoing craniotomies were measured directly to assess the accuracy of CT measurements, which were found to be within 5% error. A regression curve was plotted to demonstrate the relationship between skeletal thickness and age, with 95% coverage interval for data points. Analysis of these data showed that cranial bone thickness does increase predictably with age, and that the velocity of bone growth decreased with age and became zero at 239 months. An identifiable diploic space was apparent in 33% of children by age 1, 66% by age 2, and greater than 80% by age 3. The authors suggest that, based on these statistics, split cranial bone grafts should not be planned before age 3, and only full-thickness cranial grafts should be harvested before age 9 because of the thinness of the parietal bone. These should be split on a side table and half returned for donor site reconstruction. The authors also point out that these measurement were taken on normal children, and that conditions such as hydrocephalus or other craniofacial anomalies must be taken into consideration.--J.W. WEES
Reprint requests to Dr Ellis: Toronto's Center for Facial Cosmetic Surgery, 167 Sheppard Ave W, Willowdale, Ontario, Canada M2N1M9.
A Review of Methods Used to Project the Future Supply of Dental Personnel and the Future Demand and Need for Dental Services. Capilouto E, Capilouto ML, Ohsfeldt R. J Dent Ed 59:1, 1995 This study was a retrospective assessment of forecasts on dental education in the United States versus actual findings. Forecasts conducted by the American Association of Dental Schools (AADS), the American Dental Association (ADA), the Bureau of Health Professions (BHPr), and the Bureau of Labor Statistics (BLS) were examined from 1987 through 1992. Notable results include a failure of forecasts to predict the modest upswing in first-year dental students observed from 1990 to 1992. Other results were the substantial influx of foreign dental school graduates (FDGs) beginning in 1989. As of 1992, nearly 900 FDGs were enrolled in 35 of the nations 54 dental schools. None of the four major forecasting groups predicted this trend. The ADA, AADS, and BHPr also failed to predict the substantial (23%: from 4,964 to 6,108) increase in applicant pool from 1989 to 1992. Over the same period the total number of enrollees increased by slightly less than 100 students. Another demographic trend unmentioned in past forecasts is the 13% increase in total number of female dental school graduates seen by 1993. Conclusions drawn by the authors are that forecast analysts are not particularly accurate.--J. BROKLOFF
Reprint requests to Dr Pensler: Division of Plastic Surgery, Children's Memorial Hospital, 2300 Children's Plaza, Chicago, IL 60614.
Gore-Tex Implants for the Correction of Thin Lips. Ellis DAF, Trimas SJ. Laryngoscope 105:207, 1995 This report describes a technique of Gore-Tex implantation for the treatment of aged and thinned lips. The authors have used this technique in 11 patients over 3 years with a follow-up of at least 16 months. The Gore-Tex patches were 2 mm thick and were cut into 2- to 3-mm by 4- to 6-cm strips, depending on the size and volume to be corrected. The technique involves placement of a 12- or 14-gauge angiocath that is 2 inches in length into the labial mucosa side of the lip vermilion border deep to the junction of the white and red lip. The angiocath is then advanced along the entire length of the lip vermillion border until it exits the other side of the lip. The needle is then removed. The width of the angiocath creates an ample-sized pocket through which the Gore-Tex is then threaded. The Gore-Tex is threaded in one of the following two ways: 1) When a smaller strip such as a 2-mm width is used, a suture is passed through the end of a 14-gauge angiocath into the Gore-Tex and fastened with a suture loop. The angiocath is then pulled backward, leaving the Gore-Tex in the correct position. 2)
Reprint requests to Dr Capilouto: Dean School of Public Health, University of Alabama at Birmingham, Birmingham, AL
Lidocaine Adrenaline Tetracaine Gel Versus Tetracaine Adrenaline Cocaine Gel for Topical Anesthesia in Linear Scalp and Facial Lacerations in Children Aged 5 to 17 Years. Ernst AA, Marvez E, Nick TG, et al. Pediatrics 95:255-258, 1995 This study compared LAT (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) and TAC (0.5% tetracaine, 1:2000 adrenaline, 11.8% cocaine) gels as topical anesthetics in 95 children, aged 5 to 17 years, who reported to an inner-city emergency department with scalp or facial lacerations. The study was randomized, prospective, and double-blinded. In
971
972 the early 1980s TAC gel was introduced as a revolutionary new approach to topical anesthesia for laceration repair, but several studies have shown varying results in pediatric patients. Problems have been observed and considered because of the cocaine in the formulation. Both gels use hydroxyethyl cellulose, as well as preservatives. The final concentration of cocaine in the TAC formulation was 118 mg/cc, and the final concentration of lidocaine in the LAT formulation was 40 mg/cc. It was speculated that LAT gel would be as effective as the TAC gel and could replace it as a safer and cheaper substitute, and simultaneously remove the ingredient that makes it necessary to exercise security controls in an emergency department. Forty-seven patients were treated with TAC, and 48 received LAT. The patients' pain was assessed by both physicians and patients (or their parents). The data were analyzed using a modified multidimensional scale designed specifically for childrens' pain assessment. Results of the study showed no difference in the number of patients who were comfortable from the use of LAT or TAC gels, but the cost of the former was $32 less per patient. It was therefore concluded that the LAT gel appears to be better suited than TAC gel for topical anesthesia. Further study is needed to ascertain efficacy and safety of the normal applications of L A T . - - R . E . ALEXANDER Reprint requests to Dr Ernst: Department of Medicine, Section of Emergency Medicine, Charity Hospital, 13th Floor, 1532 Tulane Ave, New Orleans, LA 70140.
CURRENT LITERATURE muscle relaxation, accelerated healing, increased strength, reduced pain, diminished edema, and retardation of muscle atrophy. Electrical stimulation should only be used by practitioners who have a thorough knowledge of the indications and limitations. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat pain with signs and symptoms of inflammation. Acetaminophen is a more appropriate choice when the anti-inflammatory effects are not needed, because the NSAIDs have significant side effects. Up to 60 hours of medication may be needed before the peak anti-inflammatory effects occur with NSAIDs. NSAIDs do not seriously delay healing, contrary to a few published reports. Corticosteroids are very effective but have many side effects and must be used with caution. Therapeutic exercises are initiated to stimulate healing and minimize the adverse effects of prolonged immobilization. Range of motion and stretching exercises are started as soon as possible after the acute inflammation has subsided. There are three types of stretching exercise: ballistic, static, and proprioceptive neuromuscular facilitation. Isometric, isotonic, and isokinetic strengthening exercises are also used. The injured site should be protected during exercises until healing and rehabilitation are complete.--R.E. ALEXANDER Reprint requests to Dr Baumert: 12604 Grandview St, Overland Park, KS 66213-1751.
Acute Inflammation After Injury. Baumert PW. Postgrad
Temporomandibular Pain Dysfunction Disorder Resuiting From Road Traffic Accidents--An Australian Study. Probert TCS, Wiesenfeld D, Reade PC. Int J Oral
Med 97:35, 1995
Maxillofac Surg 23:338, 1994
This article, the first of three on sports injuries, reviews the RICE (Rest, Ice, Compression, and Elevation) technique and other treatments for musculoskeletal injury. Musculoskeletal injuries are among the most commonly encountered problems, and the physiologic response is influenced by age, nutritional status, degree of conditioning, general vascularity and innervation, and genetic makeup. Nevertheless, welldefined vascular, cellular, and biochemical changes occur at the site of injury that do not vary significantly between patients. The sooner the patient ceases activity, applies ice, uses an elastic compression wrap, and elevates the injured area, the better the chance for a rapid and complete recovery. Cold therapy during the initial 24 to 72 hours after injury reduces cellular metabolism and oxygen consumption in the tissues and may allow marginally viable cells to survive and thus reduce the amount of damaged tissue the body must repair. During this treatment the patient feels (progressively) uncomfortable coldness, burning, aching, and finally numbness. Cold application should be discontinued as soon as numbness occurs, to prevent frostbite. During the first 72 hours, cold should be applied as often as every other hour, depending on the amount of pain and swelling. Heat therapy should not be used until the signs and symptoms of acute inflammation have disappeared, or it could increase swelling. Treatment time should be limited to 20 minutes, and patients need to be cautioned not to use heating pads overnight. Ultrasound (continuous high-frequency acoustic energy) can provide heat to deeper tissues that cannot be reached by superficial methods. Phonophoresis is a technique that transfers topical anti-inflammatory or analgesic medications to underlying tissues by means of ultrasound. Relatively high concentrations are required. Iontophoresis is a similar method for transfering medications to underlying tissues, but uses continuous, low-voltage, direct current. Several forms of electrical stimulation are advocated that reportedly can result in
The relationship between temporomandibular pain dysfunction disorder (TMPD) and head and neck trauma is unclear. This is a retrospective analysis of Australian patients who received treatment for TMPD in 1987 from injuries sustained in "road traffic" accidents (defined as any accident on a public road involving motorized or nonmotorized vehicles and/or pedestrians). In all, 28 TMPD patients were identified from 20,672 treated for accident-related disorders (0.14%). The study shows that TMPD is uncommonly associated with direct or indirect trauma to the TM joint. Females were found to need TMPD treatment more commonly than males, in a 5:2 ratio. Overall, 75% of the subjects complained of TMPD immediately after the accident, and approximately 96% within 2 months of the accident. Whiplash injuries occurred in 10.6% of the patients (2,198), 65% of whom were females. Twelve of the TMPD patients also complained of whiplash symptoms. Mandibular fractures occurred in 1.1% of those involved in accidents (237), and 54% occurred in males. Only one of the patients sought TMPD treatment. Other injuries included skull fractures, facial bruising, closed head injuries, and other facial fractures. The authors conclude that TMPD that requires treatment is an uncommon result of road traffic accidents and is infrequently associated with a mandibular fracture or whiplash injury. Reprint requests to Mr Wiesenfeld: 5th Floor, 766 Elizabeth St, Melbourne 3000, Victoria, Australia.
An Investigation Into the Accuracy and Validity of Three Points Used in the Assessment of Autorotation in Orthognathic Surgery. Bryan DC. Br J Oral Maxillofac Surg 32:363, 1994 Because autorotation of the mandible usually accompanies surgical movement of the maxilla, it is important to accu-
Abstracts Cranial Bone Grafting in Children. Koenig W J, Donovan M, Pendsler JM. Plast Reconstr Surg 95:1, 1995
When a larger strip such as a 3-mm width is inserted, the Gore-Tex is threaded into the opening of a 12-gauge angiocath and is fastened with a suture. The angiocath is then pulled backward, leaving the Gore-Tex in the proper position. No sutures are needed to close either entrance or exit sites of the angiocath. In patients who lack philtral crest height, two small pieces can be introduced in a similar fashion into the philtrum. Patients were noted to regain a socially acceptable appearance within 1 week. The postoperative discomfort and swelling was considered minimal. The authors prefer this method over others for correction of the thinned and ptotic lip in patients who desire a more esthetically pleasing lip complex.--K.N. CHow
Cranial bone is often the graft of choice in craniofacial reconstruction because of its favorable survival, location, and minimal donor site morbidity. The purpose of this study was to evaluate cranial bone thickness in the parietal bone as it relates to age and to assess the presence or absence of a diploic space. Computed tomography (CT) scans of 96 patients between newborn and 21 years of age were examined. The thickness of the parietal bone was measured at a point two thirds the distance from the external auditory meatus and the sagittal suture on both sides, and averaged. Presence or absence of a diploic space were also recorded. Five patients undergoing craniotomies were measured directly to assess the accuracy of CT measurements, which were found to be within 5% error. A regression curve was plotted to demonstrate the relationship between skeletal thickness and age, with 95% coverage interval for data points. Analysis of these data showed that cranial bone thickness does increase predictably with age, and that the velocity of bone growth decreased with age and became zero at 239 months. An identifiable diploic space was apparent in 33% of children by age 1, 66% by age 2, and greater than 80% by age 3. The authors suggest that, based on these statistics, split cranial bone grafts should not be planned before age 3, and only full-thickness cranial grafts should be harvested before age 9 because of the thinness of the parietal bone. These should be split on a side table and half returned for donor site reconstruction. The authors also point out that these measurement were taken on normal children, and that conditions such as hydrocephalus or other craniofacial anomalies must be taken into consideration.--J.W. WEES
Reprint requests to Dr Ellis: Toronto's Center for Facial Cosmetic Surgery, 167 Sheppard Ave W, Willowdale, Ontario, Canada M2N1M9.
A Review of Methods Used to Project the Future Supply of Dental Personnel and the Future Demand and Need for Dental Services. Capilouto E, Capilouto ML, Ohsfeldt R. J Dent Ed 59:1, 1995 This study was a retrospective assessment of forecasts on dental education in the United States versus actual findings. Forecasts conducted by the American Association of Dental Schools (AADS), the American Dental Association (ADA), the Bureau of Health Professions (BHPr), and the Bureau of Labor Statistics (BLS) were examined from 1987 through 1992. Notable results include a failure of forecasts to predict the modest upswing in first-year dental students observed from 1990 to 1992. Other results were the substantial influx of foreign dental school graduates (FDGs) beginning in 1989. As of 1992, nearly 900 FDGs were enrolled in 35 of the nations 54 dental schools. None of the four major forecasting groups predicted this trend. The ADA, AADS, and BHPr also failed to predict the substantial (23%: from 4,964 to 6,108) increase in applicant pool from 1989 to 1992. Over the same period the total number of enrollees increased by slightly less than 100 students. Another demographic trend unmentioned in past forecasts is the 13% increase in total number of female dental school graduates seen by 1993. Conclusions drawn by the authors are that forecast analysts are not particularly accurate.--J. BROKLOFF
Reprint requests to Dr Pensler: Division of Plastic Surgery, Children's Memorial Hospital, 2300 Children's Plaza, Chicago, IL 60614.
Gore-Tex Implants for the Correction of Thin Lips. Ellis DAF, Trimas SJ. Laryngoscope 105:207, 1995 This report describes a technique of Gore-Tex implantation for the treatment of aged and thinned lips. The authors have used this technique in 11 patients over 3 years with a follow-up of at least 16 months. The Gore-Tex patches were 2 mm thick and were cut into 2- to 3-mm by 4- to 6-cm strips, depending on the size and volume to be corrected. The technique involves placement of a 12- or 14-gauge angiocath that is 2 inches in length into the labial mucosa side of the lip vermilion border deep to the junction of the white and red lip. The angiocath is then advanced along the entire length of the lip vermillion border until it exits the other side of the lip. The needle is then removed. The width of the angiocath creates an ample-sized pocket through which the Gore-Tex is then threaded. The Gore-Tex is threaded in one of the following two ways: 1) When a smaller strip such as a 2-mm width is used, a suture is passed through the end of a 14-gauge angiocath into the Gore-Tex and fastened with a suture loop. The angiocath is then pulled backward, leaving the Gore-Tex in the correct position. 2)
Reprint requests to Dr Capilouto: Dean School of Public Health, University of Alabama at Birmingham, Birmingham, AL
Lidocaine Adrenaline Tetracaine Gel Versus Tetracaine Adrenaline Cocaine Gel for Topical Anesthesia in Linear Scalp and Facial Lacerations in Children Aged 5 to 17 Years. Ernst AA, Marvez E, Nick TG, et al. Pediatrics 95:255-258, 1995 This study compared LAT (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) and TAC (0.5% tetracaine, 1:2000 adrenaline, 11.8% cocaine) gels as topical anesthetics in 95 children, aged 5 to 17 years, who reported to an inner-city emergency department with scalp or facial lacerations. The study was randomized, prospective, and double-blinded. In
971
972 the early 1980s TAC gel was introduced as a revolutionary new approach to topical anesthesia for laceration repair, but several studies have shown varying results in pediatric patients. Problems have been observed and considered because of the cocaine in the formulation. Both gels use hydroxyethyl cellulose, as well as preservatives. The final concentration of cocaine in the TAC formulation was 118 mg/cc, and the final concentration of lidocaine in the LAT formulation was 40 mg/cc. It was speculated that LAT gel would be as effective as the TAC gel and could replace it as a safer and cheaper substitute, and simultaneously remove the ingredient that makes it necessary to exercise security controls in an emergency department. Forty-seven patients were treated with TAC, and 48 received LAT. The patients' pain was assessed by both physicians and patients (or their parents). The data were analyzed using a modified multidimensional scale designed specifically for childrens' pain assessment. Results of the study showed no difference in the number of patients who were comfortable from the use of LAT or TAC gels, but the cost of the former was $32 less per patient. It was therefore concluded that the LAT gel appears to be better suited than TAC gel for topical anesthesia. Further study is needed to ascertain efficacy and safety of the normal applications of L A T . - - R . E . ALEXANDER Reprint requests to Dr Ernst: Department of Medicine, Section of Emergency Medicine, Charity Hospital, 13th Floor, 1532 Tulane Ave, New Orleans, LA 70140.
CURRENT LITERATURE muscle relaxation, accelerated healing, increased strength, reduced pain, diminished edema, and retardation of muscle atrophy. Electrical stimulation should only be used by practitioners who have a thorough knowledge of the indications and limitations. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat pain with signs and symptoms of inflammation. Acetaminophen is a more appropriate choice when the anti-inflammatory effects are not needed, because the NSAIDs have significant side effects. Up to 60 hours of medication may be needed before the peak anti-inflammatory effects occur with NSAIDs. NSAIDs do not seriously delay healing, contrary to a few published reports. Corticosteroids are very effective but have many side effects and must be used with caution. Therapeutic exercises are initiated to stimulate healing and minimize the adverse effects of prolonged immobilization. Range of motion and stretching exercises are started as soon as possible after the acute inflammation has subsided. There are three types of stretching exercise: ballistic, static, and proprioceptive neuromuscular facilitation. Isometric, isotonic, and isokinetic strengthening exercises are also used. The injured site should be protected during exercises until healing and rehabilitation are complete.--R.E. ALEXANDER Reprint requests to Dr Baumert: 12604 Grandview St, Overland Park, KS 66213-1751.
Acute Inflammation After Injury. Baumert PW. Postgrad
Temporomandibular Pain Dysfunction Disorder Resuiting From Road Traffic Accidents--An Australian Study. Probert TCS, Wiesenfeld D, Reade PC. Int J Oral
Med 97:35, 1995
Maxillofac Surg 23:338, 1994
This article, the first of three on sports injuries, reviews the RICE (Rest, Ice, Compression, and Elevation) technique and other treatments for musculoskeletal injury. Musculoskeletal injuries are among the most commonly encountered problems, and the physiologic response is influenced by age, nutritional status, degree of conditioning, general vascularity and innervation, and genetic makeup. Nevertheless, welldefined vascular, cellular, and biochemical changes occur at the site of injury that do not vary significantly between patients. The sooner the patient ceases activity, applies ice, uses an elastic compression wrap, and elevates the injured area, the better the chance for a rapid and complete recovery. Cold therapy during the initial 24 to 72 hours after injury reduces cellular metabolism and oxygen consumption in the tissues and may allow marginally viable cells to survive and thus reduce the amount of damaged tissue the body must repair. During this treatment the patient feels (progressively) uncomfortable coldness, burning, aching, and finally numbness. Cold application should be discontinued as soon as numbness occurs, to prevent frostbite. During the first 72 hours, cold should be applied as often as every other hour, depending on the amount of pain and swelling. Heat therapy should not be used until the signs and symptoms of acute inflammation have disappeared, or it could increase swelling. Treatment time should be limited to 20 minutes, and patients need to be cautioned not to use heating pads overnight. Ultrasound (continuous high-frequency acoustic energy) can provide heat to deeper tissues that cannot be reached by superficial methods. Phonophoresis is a technique that transfers topical anti-inflammatory or analgesic medications to underlying tissues by means of ultrasound. Relatively high concentrations are required. Iontophoresis is a similar method for transfering medications to underlying tissues, but uses continuous, low-voltage, direct current. Several forms of electrical stimulation are advocated that reportedly can result in
The relationship between temporomandibular pain dysfunction disorder (TMPD) and head and neck trauma is unclear. This is a retrospective analysis of Australian patients who received treatment for TMPD in 1987 from injuries sustained in "road traffic" accidents (defined as any accident on a public road involving motorized or nonmotorized vehicles and/or pedestrians). In all, 28 TMPD patients were identified from 20,672 treated for accident-related disorders (0.14%). The study shows that TMPD is uncommonly associated with direct or indirect trauma to the TM joint. Females were found to need TMPD treatment more commonly than males, in a 5:2 ratio. Overall, 75% of the subjects complained of TMPD immediately after the accident, and approximately 96% within 2 months of the accident. Whiplash injuries occurred in 10.6% of the patients (2,198), 65% of whom were females. Twelve of the TMPD patients also complained of whiplash symptoms. Mandibular fractures occurred in 1.1% of those involved in accidents (237), and 54% occurred in males. Only one of the patients sought TMPD treatment. Other injuries included skull fractures, facial bruising, closed head injuries, and other facial fractures. The authors conclude that TMPD that requires treatment is an uncommon result of road traffic accidents and is infrequently associated with a mandibular fracture or whiplash injury. Reprint requests to Mr Wiesenfeld: 5th Floor, 766 Elizabeth St, Melbourne 3000, Victoria, Australia.
An Investigation Into the Accuracy and Validity of Three Points Used in the Assessment of Autorotation in Orthognathic Surgery. Bryan DC. Br J Oral Maxillofac Surg 32:363, 1994 Because autorotation of the mandible usually accompanies surgical movement of the maxilla, it is important to accu-