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Item Buffered vs. Unbuffered Local Anesthesia in Mandibular Molars Diagnosed with Symptomatic Irreversible Pulpitis: A Controlled, Randomized, Double-Blind Study(2022) Alena, Peter; Spolnik, Kenneth; Ehrlich, Ygal; Warner, NedIntroduction: Profound pulpal anesthesia is not always adequate in mandibular teeth after the administration of local anesthesia, especially in the presence of irreversible pulpitis. Failure to achieve anesthesia has been seen in 30–80% of patients in teeth with a diagnosis of irreversible pulpitis. Onpharma™ developed an FDA-approved device that uses sodium bicarbonate to buffer a standard local anesthetic (LA) solution so that its pH may become closer to its pKa. Claims have been made that buffering a local anesthetic increases the anesthetic’s effect. Previous studies on the anesthetic efficacy of Onpharma’s Onset buffering system were inconclusive and may be dependent on the techniques used. Objectives: The aim of this study is to determine whether a buffered local anesthetic can lead to more profound and faster pulpal anesthesia in mandibular molars diagnosed with symptomatic irreversible pulpitis as compared to a standard, unbuffered local anesthetic. Materials and Methods: 40 total subjects completed the study. Screened and eligible subjects with a mandibular molar diagnosed with symptomatic irreversible pulpitis were randomly allocated into 2 groups so 1 group received a total of 3 cartridges of a standard, unbuffered 2% lidocaine with 1:100,000 epinephrine via inferior alveolar nerve block (IANB) followed by supplemental buccal and lingual infiltrations, while the other received the equivalent yet buffered formulation. An electronic pulp tester (EPT) was used to objectively determine baseline pulpal status of the affected tooth, followed by 2-minute interval testing following the administration of all local anesthesia. The onset of pulpal anesthesia was defined by the first of 2 consecutive EPT=80 readings, and the endodontic treatment could begin. Profound pulpal anesthesia was ultimately determined if the patient reported a comfortable pulpotomy as reflected on the Wong-Baker FACES Visual Analog Scale. Null Hypothesis 1: Subjects possessing mandibular molars diagnosed with symptomatic irreversible pulpitis will not achieve pulpal anesthesia more profoundly using buffered 2% lidocaine w/ 1:100,000 epinephrine in comparison to the standard, unbuffered anesthetic formulation. Null hypothesis 2: Subjects possessing mandibular molars diagnosed with symptomatic irreversible pulpitis will not achieve pulpal anesthesia faster using buffered 2% lidocaine w/ 1:100,000 epinephrine in comparison to the standard, unbuffered anesthetic formulation. Results: We observed a local anesthetic success rate of 45% in the buffered group, 70% in the unbuffered group, and ultimately 57.5% between both groups. The findings further indicate that the VAS scores after pulpotomy is significantly different between the 2 groups (p=0.019), with the unbuffered group having a more profound mean VAS score of 1.2 (as opposed to a buffered mean of 3.1). Regarding the time of onset for pulpal anesthesia, there was no statistically significant difference noted between the buffered and unbuffered groups. Conclusion: Based on the findings of this study, the null hypothesis 1 cannot be rejected since unbuffered 2% lidocaine with 1:100,000 epinephrine had a statistically significant increase in profound pulpal anesthesia compared to the buffered equivalent. The null hypothesis 2 cannot be rejected since there was no evidence of a significant difference in the time to pulpal anesthesia between the buffered and unbuffered groups.Item Exploration of Sinusoidal Low Frequency Alternating Current Stimulation to Block Peripheral Nerve Activity(2024-05) Horn, Michael Ryne; Yoshida, Ken; Ward, Mathew P.; Berbari, Edward J.; Schild, John H.Sinusoidal low frequency alternating current (LFAC) stimulation is a novel mode of electrical modulation observed in the Bioelectroics Lab in 2017. LFAC is capable of blocking the single fiber action potentials (APs) of the earthworm with only a few 100’s of µA. The goal of this dissertation was to further explore and characterize the LFAC waveform to determine it’s feasibility as a method for block in the mammalian peripheral nervous system (PNS). To better understand the mechanisms of LFAC block (LFACb), a blend of in-silico modeling work was explored and the predictions were validated with ex-vivo and in-vivo experiments. This dissertation is divided into five chapters. The first chapter will explore the history of bioelectricity, the current state of in-silico modeling and methods of nerve block used in the PNS. The second chapter explores a major modeling assumption, the conductivity and permittivity of the nerve laminae of a mammalian nerve bundle. Four point electrochemical impedance spectroscopy (EIS) was performed on excised canine vagus nerve to evaluate the electrical properties of the perineurium and epineurium. This study’s result, found that the corner frequency of the perineurium (2.6kHz) and epineurium (370Hz) were much lower than previously assumed. This explain a major difference between LFACb and the more established kilohertz frequency alternating current (kHFAC) block. The third chapter revisits the initial earthworm experiments during the discovery of LFACb. The effect of conduction slowing was observed in these earthworm experiments and were also seen in a mammalian canine vagus nerve and in the Horn-Yoshida-Schild (HYS) autonomic unmyelinated axon mode. These experiments showed that LFACb occurs as a cathodic block in which the sodium channels are held inactive. Chapter 4 explored the window between LFACb and LFAC activation (LFACa). The window between the two states was describes by LFAC amplitude and LFAC frequency in an in-vivo rat sciatic nerve and an in-silico model of a myelinated motor neuron, the McIntyre-Richardson-Grill (MRG) axon model. Geometrical effects were also observed by varying the bipolar pair of contacts used to deliver the LFACb waveform from an asymmetrical tripolar cuff electrode. Plantar flexor force measurements and electromyography (EMG) of the lateral gastrocnemius (LG) and soleus (Sol) were used to quantify the effects of the LFAC waveform. Convergence between in-silico modeling and in-vivo results showed promise that modeling efforts could be used with confidence to explore the LFAC block-activation more completly. LFACa was found to be highly dependent on frequency with increasing frequency lowering the threshold of activation. LFACb was shown to be mostly invariant to frequency. The final chapter takes the information found in this dissertation and summarizes it. Future work on LFAC is also proposed and the hypothesized results presented with the findings from this dissertation and available literature.Item Reversible Nerve Conduction Block Using Low Frequency Alternating Currents(2020-08) Muzquiz, Maria I.; Yoshida, Ken; Schild, John; Berbari, EdThis thesis describes a novel method to reversibly and safely block nerve conduction using a low frequency alternating current (LFAC) waveform at 1 Hz applied through a bipolar extrafascicular electrode. This work follows up on observations made on excised mammalian peripheral nerves and earthworm nerve cords. An in-situ electrophysiology setup was used to assess the LFAC waveform on propagating action potentials (APs) within the cervical vagus nerve in anaesthetized Sprague-Dawley rats (n = 12). Two sets of bipolar cuff or hook electrodes were applied unilaterally to the cervical vagus nerve, which was crushed rostral to the electrodes to exclude reflex effects on the animal. Pulse stimulation was applied to the rostral electrode, while the LFAC conditioning waveform was applied to the caudal electrode. The efferent volley, if unblocked, elicits acute bradycardia and hypotension. The degree of block of the vagal stimulation induced bradycardia was used as a biomarker. Block was assessed by the ability to reduce the bradycardic drive by monitoring the heart rate (HR) and blood pressure (BP) during LFAC alone, LFAC with vagal stimulation, and vagal stimulation alone. LFAC applied via a hook electrode (n = 7) achieved 86.6 +/- 11% block at current levels 95 +/- 38 uAp (current to peak). When applied via a cuff electrode (n = 5) 85.3 +/- 4.60% block was achieved using current levels of 110+/-65 uAp. Furthermore, LFAC was explored on larger vagal afferent fibers in larger human sized nerve bundles projecting to effects mediated by a reflex. The effectiveness of LFAC was assessed in an in-situ electrophysiological setup on the left cervical vagus in anaesthetized domestic swine (n = 5). Two bipolar cuff electrodes were applied unilaterally to the cervical vagus nerve, which was crushed caudal to the electrodes to eliminate cardiac effects. A tripolar extrafascicular cuff electrode was placed most rostral on the nerve for recording of propagating APs induced by electrical stimulation and blocked via the LFAC waveform. Standard pulse stimulation was applied to the left cervical vagus to induce the Hering-Breuer reflex. If unblocked, the activation of the Hering-Breuer reflex would cause breathing to slow down and potentially cease. Block was quantified by the ability to reduce the effect of the Hering-Breuer reflex by monitoring the breathing rate during LFAC alone, LFAC and vagal stimulation, and vagal stimulation alone. LFAC achieved 87.2 +/- 8.8% (n = 5) block at current levels of 0.8 +/- 0.3 mAp. Compound nerve action potentials (CNAP) were monitored directly. They show changes in nerve activity during LFAC, which manifests itself as the slowing and amplitude reduction of components of the CNAPs. Since the waveform is balanced, all forward reactions are reversed, leading to a blocking method that is similar in nature to DC block without the potential issues of toxic byproduct production. These results suggest that LFAC can achieve a high degree of nerve block in both small and large nerve bundles, resulting in the change in behavior of a biomarker, in-vivo in the mammalian nervous system at low amplitudes of electrical stimulation that are within the water window of the electrode.