Extracorporeal Shockwave Therapy in Dentistry: Harnessing Shock Waves for Dental Therapeutics

Long-term Results of Extracorporeal Shockwave Lithotripsy and Endoscopic Therapy for Pancreatic Stones

Shock wave therapy has seen widespread use since the 1990s to treat various musculoskeletal disorders including rotator cuff disease, but evidence of its efficacy remains equivocal. To determine the benefits and harms of shock wave therapy for rotator cuff disease, with or without calcification, and to establish its usefulness in the context of other available treatment options. We searched Ovid MEDLINE, Ovid Embase, CENTRAL, ClinicalTrials.gov and the WHO ICTRP up to November 2019, with no restrictions on language. We reviewed the reference lists of retrieved trials to identify potentially relevant trials. We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that used quasi-randomised methods to allocate participants, investigating participants with rotator cuff disease with or without calcific deposits. We included trials of comparisons of extracorporeal or radial shock wave therapy versus any other intervention. Major outcomes were pain relief greater than 30%, mean pain score, function, patient-reported global assessment of treatment success, quality of life, number of participants experiencing adverse events and number of withdrawals due to adverse events. Two review authors independently selected studies for inclusion, extracted data and assessed the certainty of evidence using GRADE. The primary comparison was shock wave therapy compared to placebo. Thirty-two trials (2281 participants) met our inclusion criteria. Most trials (25) included participants with rotator cuff disease and calcific deposits, five trials included participants with rotator cuff disease and no calcific deposits, and two trials included a mixed population of participants with and without calcific deposits. Twelve trials compared shock wave therapy to placebo, 11 trials compared high-dose shock wave therapy (0.2 mJ/mm² to 0.4 mJ/mm² and above) to low-dose shock wave therapy. Single trials compared shock wave therapy to ultrasound-guided glucocorticoid needling, ultrasound-guided hyaluronic acid injection, transcutaneous electric nerve stimulation (TENS), no treatment or exercise; dual session shock wave therapy to single session therapy; and different delivery methods of shock wave therapy. Our main comparison was shock wave therapy versus placebo and results are reported for the 3 month follow up. All trials were susceptible to bias; including selection (74%), performance (62%), detection (62%), and selective reporting (45%) biases. No trial measured participant-reported pain relief of 30%. However, in one trial (74 participants), at 3 months follow up, 14/34 participants reported pain relief of 50% or greater with shock wave therapy compared with 15/40 with placebo (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.62 to 1.94); low-quality evidence (downgraded for bias and imprecision). Mean pain (0 to 10 scale, higher scores indicate more pain) was 3.02 points in the placebo group and 0.78 points better (0.17 better to 1.4 better; clinically important change was 1.5 points) with shock wave therapy (9 trials, 608 participants), moderate-quality evidence (downgraded for bias). Mean function (scale 0 to 100, higher scores indicate better function) was 66 points with placebo and 7.9 points better (1.6 better to 14 better, clinically important difference 10 points) with shock wave therapy (9 trials, 612 participants), moderate-quality evidence (downgraded for bias). Participant-reported success was reported by 58/150 people in shock wave therapy group compared with 35/137 people in placebo group (RR 1.59, 95% CI 0.87 to 2.91; 6 trials, 287 participants), low-quality evidence (downgraded for bias and imprecision). None of the trials measured quality of life. Withdrawal rate or adverse event rates may not differ between extracorporeal shock wave therapy and placebo, but we are uncertain due to the small number of events. There were 11/34 withdrawals in the extracorporeal shock wave therapy group compared with 13/40 withdrawals in the placebo group (RR 0.75, 95% CI 0.43 to 1.31; 7 trials, 581 participants) low-quality evidence (downgraded for bias and imprecision); and 41/156 adverse events with extracorporeal shock wave therapy compared with 10/139 adverse events in the placebo group (RR 3.61, 95% CI 2.00 to 6.52; 5 trials, 295 participants) low-quality evidence (downgraded for bias and imprecision). Subgroup analyses indicated that there were no between-group differences in pain and function outcomes in participants who did or did not have calcific deposits in the rotator cuff. Based upon the currently available low- to moderate-certainty evidence, there were very few clinically important benefits of shock wave therapy, and uncertainty regarding its safety. Wide clinical diversity and varying treatment protocols means that we do not know whether or not some trials tested subtherapeutic doses, possibly underestimating any potential benefits. Further trials of extracorporeal shock wave therapy for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review. A standard dose and treatment protocol should be decided upon before further research is conducted. Development of a core set of outcomes for trials of rotator cuff disease and other shoulder disorders would also facilitate our ability to synthesise the evidence.

Objective To study the therapeutic effects of extracorporeal shock wave therapy (ESWT) on temporomandibular joint disorders (TMDs). Methods Sixty patients with a temporomandibular joint disorder were randomly divided into an ESWT group and a control group, each of 30. Both groups were given routine rehabilitation training, but the treatment group additionally received ESWT for 2 weeks. Fricton′s index was used to evaluate temporomandibular joint function. The subjects used a visual analogue scale (VAS) to evaluate their pain levels. The SF-36 scale was applied to assess their life quality. Results After two weeks of treatment, the average assessment score and VAS score had decreased significantly in both groups. After treatment the average scores for mandibular movement, muscle palpation, joint noise and joint palpation, and the palpation, dysfunction and craniomandibular indexes were all significantly lower in the ESWT group than in the control group. Significant differences were also found in the average VAS scores and on the social functioning domain of the SF-36 between the ESWT group and the control group. Conclusion ESWT combined with rehabilitation training can significantly relieve the symptoms and pain of TMDs. Key words: Temporomandibular joint; Shock wave therapy; Fricton′s index; Pain; Quality of life

Extracorporeal Shock Wave Therapy (ESWT) is effective in the treatment of calcific tendinopathy of the rotator cuff, eliciting an analgesic/anti-inflammatory action and promoting tissue regeneration. Kinesio taping (KT), another recently-introduced rehabilitative tool, exerts an analgesic and biomechanical action on joints and muscles. ESWT and KT may have a synergic effect when used in combination, but the effectiveness of the association has not been established. The aim of this study was to test if the association of KT with ESWT is superior to ESWT alone in the treatment of rotator cuff calcific tendinopathy. Randomized controlled trial. Rehabilitation Institute outpatients. Forty-two patients with rotator cuff calcific tendinopathy were randomly assigned to the experimental group (ESWT+KT, N.=21) or control (ESWT, N.=21). In the experimental group, patients underwent three sessions (once a week for 3 weeks) of ESWT with KT applied at the end of each session. Controls underwent three sessions of ESWT only. All patients were assessed before treatment (T0) and at 1 (T1), 4 (T2) and 12 weeks (T3) after the end of treatment with the following outcome measures: a visual analogue scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Subjective Shoulder Rating Questionnaire (SSRQ), and Oxford Shoulder Score (OSS). Both groups showed significant improvement in all outcome measures, but the time course differed between the two groups. At T1 vs. T0, the improvement was significantly better in ESWT+KT than ESWT on VAS (P=0.007), DASH (P<0.0001) and SSRQ (P=0.0001). Successive improvements at T2 vs. T1 and T3 vs. T2 did not differ significantly between the groups. At the end of follow-up, ESWT+KT still showed significantly greater improvement than ESWT on VAS (P=0.02) and SSRQ (P=0.038). KT associated with ESWT seems to improve the recovery in rotator cuff calcific tendinopathy with a faster therapeutic response compared to ESWT only. Our results suggest the effectiveness of using KT as adjuvant therapy to ESWT in rotator cuff calcific tendinopathy, through enhancing the short-term analgesic action and the medium- to long-term biological-regenerative effects.

BackgroundNontraumatic osteonecrosis of the femoral head (ONFH) is treated with a series of methods. High-energy extracorporeal shock wave therapy (ESWT) is an option with promising mid-term outcomes. The objective of this study was to determine the long-term outcomes of ESWT for ONFH.MethodsFifty-three hips in 39 consecutive patients were treated with ESWT in our hospital between January 2005 and July 2006. Forty-four hips in 31 patients with stage I–III nontraumatic ONFH, according to the Association Research Circulation Osseous (ARCO) system, were reviewed in the current retrospective study. The visual analog pain scale (VAS), Harris hip score, radiography, and magnetic resonance imaging were used to estimate treatment results. The progression of ONFH was evaluated by imaging examination and clinical outcomes. The results were classified as clinical success (no progression of hip symptoms) and imaging success (no progression of stage or substage on radiography and MRI).ResultsThe mean follow-up duration was 130.6 months (range, 121 to 138 months). The mean VAS decreased from 3.8 before ESWT to 2.2 points at the 10-year follow-up (p < 0.001). The mean Harris hip score improved from 77.4 before ESWT to 86.9 points at the 10-year follow-up. The clinical success rates were 87.5% in ARCO stage I patients, 71.4% in ARCO stage II patients, and 75.0% in ARCO stage III patients. Imaging success was observed in all stage I hips, 64.3% of stage II hips, and 12.5% of stage III hips. Seventeen hips showed progression of the ARCO stage/substage on imaging examination. Eight hips showed femoral head collapse at the 10-year follow-up. Four hips in ARCO stage III and one hip in ARCO stage II were treated with total hip arthroplasty during the follow-up. Three were performed 1 year after ESWT, one at 2 years, and one at 5 years.ConclusionsThe results of the current study indicated that ESWT is an effective treatment method for nontraumatic ONFH, resulting in pain relief and function restoration, especially for patients with ARCO stage I–II ONFH.

Extracorporeal shock wave (ESW) treatment has a positive effect of rescuing ischemic skin flaps. This study assessed whether ESW treatment rescues the compromised flap tissue by suppressing the apoptosis of ischemic tissue and recruiting tissue remodeling. We used a random-pattern extended dorsal-skin-flap (10 x 3 cm) rodent model. Thirty-six male Sprague-Dawley rats were divided into three groups. Group I, the control group, received no treatment. Group II received one session of ESW treatment (500 impulses at 0.15 mJ/mm(2)) immediately after surgery. Group III received two sessions of ESW treatment, immediately and the day after the surgery. Results indicated that the necrotic area in the flaps in group II was significantly smaller than that of the flaps in group I (p<0.01). Transferase dUTP-nick end labeling (TUNEL) analysis revealed a significant decrease in the number of apoptotic cells in group II. Hydrogen peroxide (H(2)O(2)) expression in circulation blood was significantly decreased in group II on the day after ESW treatment. Immunohistochemical staining indicated that compared with no treatment, ESW treatment could substantially increase proliferating cell nuclear antigen (PCNA), endothelial nitric oxide synthase, and prolyl 4-hydroxylase (rPH) expression, reduce CD45 expression, and suppress 8-hydroxyguanosine (8-OG) expression in the ischemic zone of the flap tissue. In conclusion, ESW treatment administered at an optimal dosage exerts a positive effect of rescuing ischemic extended skin flaps. The mechanisms of action of ESWs involve modulation of oxygen radicals, attenuation of leukocyte infiltration, decrease in tissue apoptosis, and recruitment of skin fibroblasts, which results in increased flap tissue survival.

Introduction: Previous studies suggest that fragmentation of pancreatic duct stones (PDS) using extracorporeal shock wave lithotripsy (ESWL) is associated with pain relief. However, the treatment may not be effective in certain subgroups.Aim: To evaluate predictors of pain relief after ESWL in patients with chronic pancreatitis and PDS.Methods: Retrospective study including patients with chronic pancreatitis undergoing ESWL for painful PDS. Analgesic use before and after the ESWL procedure was registered. We defined adequate pain relief after ESWL as ‘pain-free without analgesics or with use of weak analgesics as needed’. The study was approved by the Danish Data Protection Agency (approval number: AHH-2017-048).Results: We included 81 patients (median age 58 years; 63% men; 68% alcoholic pancreatitis). Patients underwent one to seven ESWL procedures (mean 1.7). A concurrent ERCP was performed in 17%. All patients used analgesics before the ESWL procedure (68 used opioids). After ESWL, 43 still used opioids. Thirty-two patients achieved adequate pain relief. Univariable regression analysis showed that older age predicted adequate pain relief (OR 1.09;1.03–1.16; p = .002) as did location of the stone in the head or neck (OR 2.59;1.04–6.45; p = .041). In multivariable analysis, we found that the only two predictors of adequate pain relief were age (p = .002) and the location of the stones (p = .039).Conclusion: After the ESWL, about four out of ten patients are pain-free without medication or able to manage their pain with weak analgesics. Age and the location of the stones may be considered when evaluating if patients are eligible for referral to ESWL.

Effects of intravenous ketorolac and fentanyl combined with midazolam on analgesia and side effects during extracorporeal shock wave lithotripsy.

Objective To seek the optimal treatmnt timing for extracorporeal shock wave lithotripsy(ESWL) in patients with ureteral calculi-induced renal colic. Methods A total of 505 patients with ureteral calculi-induced renal colic were followed and observed, and all patients were divided into three groups according to the time interval from the first colic attack to ESWL, including 123 patients treated by ESWL in the attack of colic or the emergency ESWL(group A), 162 patients treated by ESWL in 3~6 days after pain relief (group B) and 220 patients treated by ESWL after 7 days of pain relief (group C). Success rate of fragmentation in the first time of ESWL, stone-free rate after 2 weeks of operation, pain recurrence rate and percentage of renal infection were evaluated. Results All patients with renal colic in group A were cured, the rate of renal colic relieving was 100%.The success rate of fragmentation , stone-free rate after 2 weeks of operation in the group A and the group B were higher than those in the group C(93.5% vs. 84.6%, 94.4% vs. 84.6%, 87.0% vs. 74.1%, 85.8% vs. 74.1%), the difference was statistically significant, respectively(P 0.05). The pain recurrence rate and percentage of renal infection of the group A were 50.4% and 17.1%, respectively, which were higher than those of the group B(4.9% and 5.6%, respectively, P<0.01) and the group C(6.8% and 5.9%, respectively, P<0.01). Conclusions ESWL should be used earlier in the patients with ureteral calculi-induced renal colic, and the application of it to renal colic at acute stage is effective with high rate of pain relief.The optimal treatmnt ti-ming for ESWL is within 3~6 days after pain relief. Key words: Kidney Calculi; Ureteral Calculi; Lithotripsy

PROSPECTIVE RANDOMIZED TRIAL COMPARING SHOCK WAVE LITHOTRIPSY AND URETEROSCOPY FOR MANAGEMENT OF DISTAL URETERAL CALCULI

Recently, shock wave therapy has been investigated as an adjuvant therapy in the treatment of acute and chronic wounds. There are several devices with focused and unfocused shock waves that have been administered to a heterogenous group of wounds. Encouraging preclinical and clinical studies suggest that shock wave therapy may promote wound healing with little or no adverse events, prompting investigations into the mechanism of action and additional clinical trials. The peer-reviewed literature within the past 10 years was studied using an evidence-based approach. Preclinical studies demonstrate that shock wave therapy affects cellular function and leads to the expression of several genes and elaboration of growth factors known to promote wound healing. Limited clinical trials are encouraging for the use of shock wave therapy in the treatment of acute and chronic wounds. Serious complications, including wound infections, bleeding, hematomas, seromas, and petechiae, have not been reported in the largest of these studies. Shock wave therapy is an intriguing physical modality that may play an important role as an adjuvant therapy in wound healing. To date, there is no consensus on which wounds are most likely to benefit from shock wave therapy and what the optimal power, degree of focus, and frequency or number of cycles should be. Well-designed preclinical and clinical studies are necessary to better understand shock wave therapy in wound healing.

<h3>Introduction</h3> Extracorporeal shock wave lithotripsy (ESWL) of pancreatic duct stones, followed by endoscopic retrograde cholangio-pancreaticography (ERCP) with mechanical clearance of the pancreatic duct, and subsequent stenting is an established treatment...

Distraction osteogenesis has widespread clinical use in the treatment of congenital and acquired craniofacial deformities. Nonetheless, during the prolonged consolidation period, the newly regenerated bone carries the risk of complications. A known method for enhancing bone healing is extracorporeal shock wave therapy, which has been shown to induce neovascularization and promote tissue regeneration. The authors investigated whether extracorporeal shock wave therapy can accelerate bony consolidation and regeneration in distraction osteogenesis of the rat mandible and at which stage of distraction osteogenesis it should be applied. Twenty-four male Sprague-Dawley rats were subjected to distraction osteogenesis of the right mandible (latency period, 3 days; distraction period, 10 days; 0.5 mm/day). Experimental groups consisted of the following: group I (control), no extracorporeal shock wave therapy; group II, extracorporeal shock wave therapy (0.18 mJ/mm(2)) at the latency period; and group III, extracorporeal shock wave therapy (0.18 mJ/mm(2)) at the consolidation period. Explants were removed for evaluation after 4 weeks of consolidation. Histologic evaluation showed well-developed cortical cortex and a higher degree of bone formation and mature bone in group III; micro-computed tomography showed significantly increased bone mineral density, bone volume fraction, and trabecular thickness; immunohistochemistry demonstrated significantly increased expression of bone morphogenetic protein-2, vascular endothelial growth factor, and proliferating cell nuclear antigen. Extracorporeal shock wave therapy application at the consolidation period during distraction osteogenesis in the rat mandible enhances bone formation and osteogenic and angiogenic growth factors, improves bone mechanical properties, and accelerates bone mineralization.

Immediate Dose–Response Effect of High-Energy Versus Low-Energy Extracorporeal Shock Wave Therapy on Cutaneous Microcirculation

Background:The effectiveness of extracorporeal shock wave therapy (ESWT) has been demonstrated in various medical fields, including burn medicine. It promotes wound healing, improves blood flow, and modulates the inflammatory responses. The recovery speed and outcomes of skin diseases are influenced by the skin microbiome; however, studies examining the effects of specific treatments on the skin microbiome are lacking. This study investigated the impact of ESWT on the skin microbiome of burn patients, focusing on the microbial diversity and community structure within burn scars.Materials and methods:In the retrospective case–control study, 19 patients with burn scars were treated with ESWT, and changes in their skin microbiome were evaluated. ESWT was administered weekly for 3 months, and samples were collected from the ESWT-treated burn scars and untreated normal skin. Blood chemistry, and pain and itching scores were evaluated during sample collection. The collected samples were then subjected to 16S rRNA sequencing. Microbial community analysis was conducted using the QIIME2 and R packages.Results:After ESWT, changes in alpha diversity indices were observed in burn scars. Faith phylogenetic diversity (P<0.05) and observed features (P<0.01) increased, whereas the evenness index decreased (P<0.01); no marked changes were noted in untreated skin. Beta diversity analysis showed stable microbial community structures in both the treated and untreated areas. A considerable increase in Micrococcus and Staphylococcus abundance was observed. Network analysis revealed a more open microbial network structure after ESWT, indicating adaptive changes in the microbial community.Conclusion:ESWT enhances microbial diversity and modifies microbial community structure in burn scars, promoting a more balanced and functionally supportive microbiome. ESWT aids in scar remodeling and positively influences skin microbiome dynamics, contributing to improved skin health and recovery.