Local Anesthetics

All experiments were performed in accordance with the National Institutes of Health guidelines and regulations. The animal protocol was approved by the Massachusetts General Hospital (Boston, Massachusetts) Standing Committee on the Use of Animals in Research and Teaching. Efforts were made to minimize the number of animals used. Since it is technically difficult to perform an epidural or spinal anesthesia in mice, we have established an animal model of peripheral surgery in the abdomen under local anesthesia in mice. WT C57BL/6J mice (9 month-old, The Jackson Laboratory, Bar Harbor, ME; and 18 month-old, National Institute of Aging, Bethesda, MD), and AD Tg mice [B6.Cg-Tg(APPswe, PSEN1dE9) 85Dbo/J, 9 month-old, The Jackson Laboratory] were used in the studies. The mice were randomly assigned to a surgery or control group by weight. The mice were gently restrained to a heating pad (37 C°) using paper tape. A local anesthetic bupivacine (0.5% and 0.1 ml) was injected into the skin and subcutaneous tissue of the abdominal area. A 2.5 cm incision was made in the middle of the abdomen to open and then close the abdominal cavity in the mouse. The procedure lasted about five minutes. We did not use sedative medicine in an effort to reveal the effects of surgery alone and to minimize all other variables. EMLA cream (2.5% lidocaine and 2.5% prilocaine) was used every 8 hours for the first and second post-operative days to treat the surgery-associated pain. We did not use antibiotics because the procedure was aseptic. The non-surgery (control) mice underwent the same procedure, only without the incision. In the intervention studies, each mouse received compound E (the inhibitor of γ-secretase, which can reduce Aβ generation) (3 mg/kg, IP, Enzo Life Sciences Inc., Farmingdale, NY, Cat. Number: ALX-270-415) or saline daily for 7 days post-surgery20 (link).

The ADHS included a clinical examination and a questionnaire [13 ]. The content included: major indicators of oral health and function, dental diseases, urgent conditions such as pain and sepsis, complex treatments received, oral health risk factors and behaviour, service considerations and outcomes including access and barriers to care. The breadth of subject areas is too great (p21 Foundation Report) in scope for inclusion in this paper. Hence it is the later aspect of barriers and specifically, dental anxiety, that this paper is focused. Regularity of attendance was established from the questionnaire. The wording was: “In general do you go to the dentist for… (1) a regular check up, (2) an occasional check up, (3) or only when you’re having trouble with your teeth/dentures”.
To assess dental anxiety we employed the MDAS, which asks participants to rate: how anxious one feels the day before a dental appointment, then when in the waiting room, waiting for the receipt of drilling, scaling and a local anaesthetic injection. Responses range from ‘not anxious’ (scored 1) to ‘extremely anxious’ (scored 5). The five items are summed to create a total score, which has a range from a minimum of 5 to a maximum of 25. Total scores of 5 and 25 would denote: no dental anxiety and extreme dental anxiety, respectively. Reliability of the English language version from original investigation [3 (link)] of the MDAS is good (internal consistency= 0.89; test-retest= 0.82). The scale can be downloaded:
http://medicine.st-andrews.ac.uk/supplemental/humphris/dentalAnxiety.htm. The item wording is reproduced in Table 1 and the scale layout can be reproduced from the dedicated website download.

For the PTED group, the surgical procedure (based on the L4–L5 segment of DLS) was performed following methods reported in the literature [18 (link)]. The following steps were performed: (1) part of the superior articular process (SAP) of L5 was removed. A soft pillow was placed under the patients' waist, while the patient was in the lateral decubitus position with their knee and hip flexed. The incision was located 8–12 cm from the midline horizontally and 1–3 cm above the iliac on the side with leg pain. The mixed local anesthetic, which consisted of 30 mL 1:200,000 epinephrine and 20 mL 2% lidocaine, was only used in PTED group. After 5 mL of the mixed anesthetic was inserted into the skin at the entry point, 20 mL was inserted into the trajectory, 15 mL was inserted into the articular process, and 10 mL was inserted into the foramen. Then, 0.8–1.0 cm of skin and the subcutaneous fascia were incised. Drills were used to resect the ventral osteophytes on the SAP. The PTED system (Hoogland Spine Products, Germany) was inserted (Fig. 1). (2) Parts of the ipsilateral ligamentum flavum, perineural scar, and extruded lumbar disc material were completely resected with endoscopic forceps (Fig. 2). (3) The superior endplate of the L5 vertebral body was removed by endoscopic micro punches and a bone knife. Therefore, 270-degree decompression of the traversing nerve root was achieved (Fig. 3). The drainage tube was placed after hemostasis was reached.Fig. 1

Fluoroscopic views. A, B The drill was inserted to resect the LF and the ventral osteophytes on the SAP. C, D The working cannula was placed

Fig. 2

Endoscopic views. A Endoscopic view of the hypertrophic posterior longitudinal ligament, extruded disc material, and perineural scar. B–G After the endoscopic instruments were used to carefully remove the vertebral body, ventral decompression of the traversing nerve root (L5) was completed. H The dura mater was torn

Fig. 3

Illustrations of the 270-degree PTED. A, B Specific pathologic features of LRS-DLS. C, D Final view of the nerve 270-degree decompression status and the restoration of the lateral recess

For the MIS-TLIF group, the surgical procedure was performed in accordance with methods reported in the literature [19 (link)]. After successful general anesthesia with tracheal intubation, the patient was placed in a prone position with chest and hip pads, and the L4–L5 intervertebral space was marked with X-ray fluoroscopy. The skin and subcutaneous fascia were cut; a trans-muscular surgical corridor was created with two micro-laminectomy retractors docking on the facet joint complex. After exposing the bony structure, part of the lamina and inferior articular process of L4 and the upper L5 articular process were removed with the rongeur on the ipsilateral side, and the hypertrophic ligamentum flavum was peeled backward. If MRI showed contralateral lateral recess stenosis, then predecompression was performed on the contralateral side. After decompression on the dorsal side, the nucleus pulposus and endplate cartilage were removed with forceps. An appropriate cage (Medtronic) filled with autograft from laminectomy was placed in the center of the intervertebral space via the Kambin’s triangle area. After adequate hemostasis was achieved, two drainage tubes were placed and removed when the drainage volume was < 50 mL/d.
Postoperatively, patients was treated with oral nonsteroidal anti-inflammatory drugs and antibiotics for 3 days. All patients were encouraged to perform straight leg raising 1 day postoperatively, and moderate off-bed activity with a brace 2–3 days postoperatively. On the third postoperative day, patients were allowed to go home if their lower extremity pain symptoms were effectively relieved with no evidence of infection. The patient demographics and perioperative outcomes were compared. The VAS score, ODI, and modified Macnab criteria were used to evaluate the clinical outcomes [20 (link)].

The patients were randomly separated into two groups by simple randomization method by computer. No conservative treatment was applied before arthrocentesis. Only arthrocentesis was given to patients in the control group (n:14), while the TX group (n:16) received both arthrocentesis and a 2-ml injection of tenoxicam (Oksamen-L, Mustafa Nevzat İlaç Sanayi, Istanbul, Turkey) to the temporomandibular joint (Fig. 1) The preauricular area was cleaned with 10% povidone-iodine solution. Ultracaine D-S Forte® (Sanofi-Aventis, İstanbul, Turkey) was used as a local anesthetic. The entry point was along the lateral canthus-tragus line (Holmlund-Hellsing line), 10 mm away from the anterior tragal midline and 2 mm under it. The second point was along the lateral canthus-tragus line, 20 mm away from the anterior tragal midline and 10 mm under it [22 ].Fig. 1

Arthrocentesis procedure

Preoperative measurements and arthrocentesis procedures were performed by the same surgeon (GYY). All patients were irrigated with approximately 100 ml of Ringer’s lactate. In the control group, no additional injections were given, but in the TX group, 2 ml(20 mg) of tenoxicam was injected intraarticularly following arthrocentesis. A drug containing paracetamol was prescribed to relieve post-procedure pain. A soft diet was recommended to the patients. Physical therapy, occlusal splint or other preventive treatments were not applied during the follow-up period. The form in which the data of the patients is processed is given in Fig. 2.Fig. 2

A patient form sample

Patients were followed for 6 months. The outcome variables were pain scores on a visual analog scale (VAS), VAS joint sounds (crepitus sounds), and maximum mouth opening (MMO), which were measured at baseline, one week, one month, three months, and six months after the arthrocentesis. To measure the VAS value, a 10-cm-long numbered line was created. The patient chose a point on the line, the corresponding value was measured with a ruler, and a score was given. MMO was gauged between the incisal edges of the maxillar and mandibular central incisors. Outcome variables were evaluated postoperatively by the surgeon (AK), who was unaware of the treatment procedures for all patients.