10, No. CONTRAINDICATIONS: IOPP is contraindicated for use on electrically sensitive patients, patients with pacemakers, patients with known drug allergies to the drug being administered. Common Uses for Iontophoresis In rehabilitation medicine, including physical therapy, iontophoresis is used to reduce inflammation that might be seen in musculoskeletal conditions such as lateral epicondylitis, medial epicondylitis, plantar fasciitis, tendo-nitis/bursitis, rheumatoid arthritis, and enthesopathic conditions of various origins. Careers. Code Number Description. IOPP is contraindicated for use on electrically sensitive patients, patients with pacemakers, patients with known drug allergies to the drug being administered. Passive flexion and extension range of motion at the metatarsophalangeal joint was 5 degrees. Iontophoresis of lecithin vesicles of cyclosporin A. Electrical Stimulation (Manual) This modality includes the following types of electrical stimulation: Establish specific iontophoresis application procedures and techniques. Most studies of iontophoresis for other indications are not well-designed. Iontophoresis (BETTER)-use electrical current to deliver meds-Indications - anti-inflamm, calcific tendonitis, adhesive capsulitis, soft tissue pain, skin ulcers, hyperhydrosis-C/I - allergies to meds, across the chest and pacemaker, PVD, preggo, osteoporosis, sensory deficit 14, No. 1 Originally referred to as ion transfer, it was first described by LeDuc in 1903 as a technique of transporting chemicals across a membrane using an electrical current as a driving force. Jacksonville Beach, FL 32250, Direct Orthopedic Therapy 2022. Iontophoresis is a form of transdermal drug delivery that utilizes electrical current to drive or push ionized drugs through the skin's outermost layer. 13, No. Physical therapy services are part of a constellation of rehabilitative services designed to improve or restore physical functioning following disease, injury, or loss of a body part. 2, Advanced Drug Delivery Reviews, Vol. Inspect the skin for burns or reactions. Examination revealed intact sensation and proprioception, with trace active movements of flexion and extension at both the metatarsophalangeal and interphalangeal joints. Due to the lack of research into its affect on fetal health, iontophoresis is contraindicated in pregnancy. Muscle Nerve. The goal of this clinical research study is to determine if there is a difference in time to meet return to sport criteria for Pediatric patients with apophysitis of the knee who receive iontophoresis with Dexamethasone Sodium Phosphate (DSP) and Physical Therapy (PT) as those who receive iontophoresis with placebo and PT or PT alone. 2, Clinics in Sports Medicine, Vol. A treatment method by which ionized medication, (e.g. How IontoPatch Works Typically the patient is responsible for filling the prescription and bringing the medication to the treatment session. 7, No. 2, Medicine & Science in Sports & Exercise, Vol. Browser Support. Amirjani N, Ashworth NL, Watt MJ, Gordon T, Chan KM. Built by Rehab CEOs. Limitations and/or Medical Necessity-General Physical Therapy Guidelines #3 added "treatment" to the third sentence. Set the treatment time. 7, 9 - 11 ultrasound has also been shown to promote healing of some acute bone. 3, 12 August 2014 | Southern African Journal of Anaesthesia and Analgesia, Vol. The efficacy of phonophoresis as a treatment ULTRASOUND technique has been well documented for use in a variety of orthopaedic diagnoses, despite the For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points . 46, No. https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=2223§ionid=173786078. 117, No. An official website of the United States government. 708 3rd St N, Please click Continue to continue the affiliation switch, otherwise click Cancel to cancel signing in. The studies have small sample sizes, lack appropriate control groups, and usually do not have objective outcome measures. [13] It is true that both techniques are used to deliver chemicals to various biologic tissues. 11, No. The Oncologist 1996;1. Iontophoresis is a therapeutic technique that involves the introduction of ions into the body tissues by means of a direct electrical current. 1 Temporal Cont, Medicinal Research Reviews, Vol. As specific conductivity potentials were established for various chemicals and drugs, it has been shown that numerous broad spectrum, site-specific, systemic-acting medications can be directly introduced across intact skin to treat a wide range of maladies. Otherwise it is hidden from view. 3, Clinical Pharmacokinetics, Vol. It can also be used for scar tissue massage. Must have a day between treatments. These wireless iontophoresis treatment kits include synthetic patches that are engineered to administer transdermal dosages on a set schedule. 2 Since that time, the use and popularity of iontophoresis has . 25, No. SOLUTIONS TO CLINICAL DECISION-MAKING EXERCISES. 618, No. The treatment drugs were 1 cubic centimeter, 4 milligrams per milliliter of dexamethasone sodium phosphate (Decadron) combined with 2 cubic centimeters of 4% Xylocaine. The reason why pacemakers and metal orthopedic implants are considered a contraindication for iontophoresis is because the parts of the body that the current must go through should not contain metal . Identify the different ions most commonly used in iontophoresis. Do not place a hot pack or ice pack directly over the electrodes or treatment area. NCI CPTC Antibody Characterization Program. It is also contraindicated for the use over damaged or denuded skin or recent scar tissue, across the temporal region and for treatment in the orbital regions. 2. government site. 7, No. 4, Journal of Pharmaceutical Sciences, Vol. 2009 May;39(5):627-33. doi: 10.1002/mus.21300. Iontophoresis is a non-invasive and painless method of delivering anti-inflammatory medications deeper into the body's issues. It is a great tool for physical therapy to reduce inflammation and pain in conditions like tendonitis, which causes muscle inflammation. Iontophoresis is a therapeutic technique that involves the introduction of ions into the body tissues by means of a direct electrical current.1 Originally referred to as ion transfer, it was first described by LeDuc in 1903 as a technique of transporting chemicals across a membrane using an electrical current as a driving force.2 Since that time, the use and popularity of iontophoresis has varied. 3. 9, No. Recently, there has been increased interest in using this technique for the transdermal delivery of medications, both ionic and nonionic. These include: Decrease inflammation Decrease pain Decrease muscle spasm Decrease swelling and edema Reduce calcium deposits in the body Manage scar tissue Your physical therapist will work with you to decide on the treatment goals and the rationale for using iontophoresis. 84, No. Electrotherapy / Electrophysical Agents (APAs) Electrophysical agents (EPAs) are those modalities that administer thermal, mechanical, electrical or light energy to the patient to provide physiological effects and therapeutic benefits. 1, Journal of Athletic Training, Vol. As far far indications of phonophoresis are concerned there are as follows, Sustain release drug delivery system (SRDD) Extra amount to be delivered in a continuous way Patient is unable to take medicine orally in bulk amount Unconscious patient Drugs that have poor absorption in intestine Drug required at regular intervals Does acetic acid iontophoresis accelerate the resorption of calcium deposits in calcific tendinitis of the shoulder? 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Scifers, James R., and William E. Prentice. HHS Vulnerability Disclosure, Help Phonophoresis is a physical therapy technique that combines ultrasound and topical medications. Physiotherapists use these as an adjunct to other treatment and management techniques in most situations. Regarding: Rosenthal DI, Glatstein E. "We've Got a Treatment, but What's the Disease?" Ultrasound waves. Innovative iontophoresis electrodes deliver soluble salts and other drugs into the body without disturbing tissue. It is a great tool for physical therapy to reduce inflammation and pain in conditions like tendonitis, which causes muscle inflammation. Iontophoresis is a method of non-invasive transdermal drug delivery based on the transfer of charged molecules using a low-intensity electric current 1). This technique has been used in physical therapy to introduce ionic medications through the skin, primarily for a local effect. 11, New England Journal of Medicine, Vol. 1, Clinics in Sports Medicine, Vol. Evidence This article includes an overview of the history of iontophoresis and a . Its a form of electrical stimulation used to administer specific drugs in our bodies. Outline appropriate monitoring and toxicity of iontophoretic analgesia. 6, Archives of Physical Medicine and Rehabilitation, Vol. The treatment should not be done on consecutive days. Please enable it to take advantage of the complete set of features! Bethesda, MD 20894, Web Policies Accessibility
Spasms can also be reduced to a minimum with this medication. How is Iontophoresis Applied? This is possibly the reason why biofeedback should be used with caution in acute psychiatric episodes. Both types of proximal procedures included bursectomy and local debridement. Clinicians manipulate the duration or the amplitude of the current, but it is not known which is more effective. 32, No. It is also contraindicated for the use over damaged or denuded skin or recent scar tissue, across the temporal region and for treatment in the orbital regions.
Crit Rev Ther Drug Carrier Syst. 41, No. 2, Scandinavian Journal of Medicine and Science in Sports, Vol. sharing sensitive information, make sure youre on a federal Please consult the latest official manual style if you have any questions regarding the format accuracy. A topical medication is a medication that's applied directly to your skin. But it also helps distribute the dexamethasone, lidocane, etc to a larger surface area. In the past it has sometimes been called Electromotive Drug Administration, though in modern therapy, this is a rarely employed term. If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. 1, 1 November 1999 | Journal of Orthopaedic & Sports Physical Therapy, Vol. 5, 23 April 2016 | The American Journal of Sports Medicine, Vol. Before Iontophoresis for transdermal drug delivery has . Boinpally RR, Zhou SL, Devraj G, Anne PK, Poondru S, Jasti BR. Accessibility Corticosteroid iontophoresis to treat carpal tunnel syndrome: a double-blind randomized controlled trial. 1, Oral and Maxillofacial Surgery Clinics of North America, Vol. 2004 Apr 15;274(1-2):185-90. doi: 10.1016/j.ijpharm.2004.01.016. Journal of Orthopaedic & Sports Physical Therapy, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Vol. This drug reduces swelling and increases mobility. One of the most significant advances was the integration of patient education. This site uses cookies to provide, maintain and improve your experience. Phonophoresis, which is discussed in detail in Chapter 10, involves the use of acoustic energy in the form of ultrasound to drive whole molecules across the skin into the tissues, whereas iontophoresis uses an electrical current to transport ions into the tissues.97. Explain the basic mechanisms of ion transfer. Phonophoresis Alternatively, phonophoresis is the application of topical medication by skin absorption and deep tissue distribution facilitated by ultrasound waves. a. 12, No. You can discuss your goals with physical therapists. 3, Advanced Drug Delivery Reviews, Vol. 54.37.119.1
IOPP is the use of a direct current to drive medications such as anti-inflammatory steroids and local anesthetics through the skin into underlying tissues. Effects of iontophoretic versus injection administration of dexamethasone, Iontophoresis with cortisone in the treatment of lateral epicondylalgia (tennis elbow)-a double-blind study, Mobilization with Movement as an Adjunct Intervention in a Patient with Complicated De Quervain's Tenosynovitis: A Case Report, Optimisation of Treatment by Applying Programmable Rate-Controlled Drug Delivery Technology, The Immediate Effects of Lidocaine Iontophoresis on Trigger-Point Pain, Skin pH Changes Associated With Iontophoresis, Physical Therapy, Chiropractic Manipulation, or an Educational Booklet for Back Pain, Treatment of Plantar Fasciitis by lontophoresis of 0.4% Dexamethasone, The role of physical agents in modulating pain, The efficacy of dexamethasone iontophoresis for the treatment of rheumatoid arthritic knees: A pilot study, The effects of electric current applied to skin: A review for transdermal drug delivery, Iontophoresis: an alternative to the use of carriers in cutaneous drug delivery, A robust transcutaneous electro-muscle stimulator (RTES): a multi-modality tool, Iontophoresis: An overview of the mechanisms and clinical application, Physical interventions in the management of pain in arthritis an overview for research and practice, lontophoretic Transdermal Delivery of Salicylic Acid and Lidocaine to Local Subcutaneous Structures, Iontophoresis in medicine: Possible applications in urology, Structure-transport relationships in transdermal iontophoresis, Iontophoresis of dexamethasone: laboratory studies, Nonsurgical Management of Traumatic Trigeminal Neuralgias and Sensory Neuropathies, Iontophoretic delivery of propranolol hydrochloride through human epidermis, Iontophoretic delivery of for postoperative analgesia, Concepts and System Design for the Rate-Controlled Drug Delivery, Transdermal Drug Delivery and Delivery Systems, Electronic Control of Iontophoretic Drug Delivery, Non-Invasive Drug Delivery Systems for the Management of Postoperative Pain, New developments in drug delivery systems, In Vitro Iontophoretic Studies Using a Synthetic Membrane, Iontophoresis-facilitated transdermal delivery of verapamil I. What should determine the clinician's decision to use one or the other? Following treatment: Remove electrode pads. 8, No. The expansion of available medications for delivery via iontophoresis has drawn new attention to this therapeutic modality. It is critical to point out the difference between iontophoresis and phonophoresis since the two techniques are often confused and occasionally the two terms are erroneously interchanged. Dosage for the galvanic stimulation for iontophoresis varies. A case study, Cumulative trauma disorder of the upper extremity from occupational stress, Iontophoretic delivery of drugs: Fundamentals, developments and biomedical applications, Application of Modalities in Overuse Syndromes, Physical Therapy Treatment of Knee Extensor Mechanism Disorders: Comparison of Four Treatment Modalities*, Comparative Study using Four Modalities in Shinsplint Treatments*, The Treatment of Soft Tissue After Spinal Injury, Osgood-Schlatter Disease: Review of Literature and Physical Therapy Management. Unable to load your collection due to an error, Unable to load your delegates due to an error. Iontophoresis is a process in which electrically charged molecules or atoms are driven into tissue with an electrical field . All studies reported a significant improvement of symptoms or satisfaction rates of 72% to 100%. and transmitted securely. 34, No. Severe psoriasis limiting range of motion.
2, Journal of Controlled Release, Vol. Federal government websites often end in .gov or .mil. Learn More Common Uses for IontoPatch As a noninvasive therapy, iontophoresis is growing in popularity among anesthesiologists, pediatricians, general and orthopedic surgeons, burn specialists, and the dental community. [Iontophoresis: an old therapeutic principle in a new light]. 2, No. GENERAL THERAPY GUIDELINES. Iontophoretic Administration of Dexamethasone Sodium Phosphate for Acute Epicondylitis: A Randomized, Double-Blinded, Placebo-Controlled Study, Effects of Iontophoresis Current Magnitude and Duration on Dexamethasone Deposition and Localized Drug Retention. For a typical treatment of 40mA, you might set up treatment for 10 minutes of 4.0 mA/min or 20 minutes of 2.0 mA/min. During iontophoresis, a medical device uses mild electrical currents to deliver medication across biological membranes, often while your affected body part is submerged in water. Leanne L. Burns, PT, MPT, President/Owner, Never attempt to reuse disposable assemblies, Advise patients of skin irritations or burns that may occur, Do not use electrodes that appear damaged or altered, Do not apply the electrodes over the temporal or orbital regions, Patients with known skin allergies should use lower current settings. The evaluation, treatment or prevention of disability, injury, disease, or other condition of health using physical, chemical, and mechanical means including, but not limited to heat, cold, light, air, water, sound, electricity, massage, mobilization, and therapeutic exercise with . Clinicians must be aware of state law that may regulate the ability of a clinical setting to store medication for individual patients. Iontophoresis electrodes and lead wire systems serve as an important medical alternative when patients cannot receive drugs via hypodermic injection. Iontophoresis Application 1. 4, No. Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. 3, Journal of Controlled Release, Vol. Iontophoresis is widely used in the treatment of overuse conditions such as epicondylitis and plantar fasciitis.49,50 Yarrobino and coworkers 49 investigated lidocaine iontophoresis (LI) in patients with subacute to chronic epicondylitis using 80 mA/min, low-current, long-duration LI over a 24-hour period. Iontophoresis is a form of electrical stimulation that physical therapist use to administer medication into a patient's body through the skin. The treatment drugs were 1 cubic centimeter, 4 milligrams per milliliter of dexamethasone sodium phosphate (Decadron) combined with 2 cubic centimeters of 4% Xylocaine. 3, Journal of Controlled Release, Vol. 1, 1 January 2006 | Physiotherapy Research International, Vol. 10, 30 August 2017 | The American Journal of Sports Medicine, Vol. 2, No. It is one the most commonly used anti-inflammatory medications and is used in iontophoresis treatments. Acetic acid is used to reduce calcium deposits in the body. Thirty-eight of the 50 patients had an excellent relief of pain and symptoms . 2, Journal of Pain and Symptom Management, Vol. . POLICY HISTORY Iontophoresis has been used to reduce sweating and enhances the delivery of drugs and macromolecules into and through the skin. In vitro evaluation and mechanistic studies, Effect of iontophoretically delivered dexamethasone on muscle performance in a rheumatoid arthritic joint. FOIA Iontophoresis is used to treat acute and subacute inflammation. Bookshelf Using a low-level electrical current applied to the skin though using a electrode, iontophoresis delivers medication molecules through the skin and into underlying tissue. 8, No. Cardiac Arrhythmia. This site needs JavaScript to work properly. The .gov means its official. Using the positive charge electrode, a medication that is a positive charge is loaded on the positive electrode which is push through the skin, and attracted toward the negative electrode. Dexamethasone. . Depending on the ionized drugs being administered, the indications of iontophoresis vary. Under Coverage Indications, Limitations and/or Medical . 31, No. 3, 1 March 2002 | Journal of Orthopaedic & Sports Physical Therapy, Vol. Fifty patients with various musculoskeletal inflammatory conditions were treated with iontophoresis (direct current 5 milliamperes, 20 minutes). 2, 1 November 1986 | Journal of Orthopaedic & Sports Physical Therapy, Vol. It is a negatively charged ion used to treat scar tissue or keloid scars (excessive connective tissue growth at injury point). Iontophoresis Units. There were no significant side effects. Education Law Section 6731 - Definition of physical therapy. Brukner & Khan Clinical Sports Medicine Audio & Video Selection, Pharmacology for the Physical Therapist Cases, Physical Therapy Case Files: Neurological Rehabilitation, Physical Therapy Case Files: Orthopedics, Principles of Rehabilitation Medicine Case-Based Board Review, IONTOPHORESIS EQUIPMENT AND TREATMENT TECHNIQUES, TREATMENT INDICATIONS AND CONTRAINDICATIONS. Iontophoresis in drug delivery: basic principles and applications. It is commonly used to treat tendonitis. the steroidal anti-inflammatory dexamethasone) is driven through the skin by an electric current so that it reaches deep tissues. Iontophoresis is safe, effective and inexpensive. 6, No. Ionto treatment lasts between 10 and 15 minutes and may be given either before or after the exercise . Tap water can be used to create positive or negative electrodes in a foot or hand immersion bath. Disclaimer, National Library of Medicine . Contraindications for iontophoresis are pacemakers, pregnancy, cancer, decreased sensation, and over broken/bleeding skin (Hecox, Mehreteab, Welsberg, & Sanko, 2006). Int J Pharm. 1, 2022 Journal of Orthopaedic & Sports Physical Therapy d/b/a Movement Science Media, Iontophoresis: Clinical Research in Musculoskeletal Inflammatory Conditions, https://www.jospt.org/doi/10.2519/jospt.1982.4.2.109, The short-term effectiveness of low-level laser, phonophoresis, and iontophoresis in patients with lateral epicondylosis, Treatment management of children with juvenile idiopathic arthritis with temporomandibular joint involvement: a systematic review, The Influence of Dexamethasone with Lidocaine Hydrochloride Iontophoresis in Recreational Tennis Players Suffering from Lateral Elbow Tendinopathy, Microdialysis and Delivery of Iontophoresis-Driven Lidocaine Into the Human Gastrocnemius Muscle, In Vitro Optimization of Dexamethasone Phosphate Delivery by Iontophoresis, Lidocaine iontophoresis mediates analgesia in lateral epicondylalgia treatment, Effectiveness of iontophoresis of anti-inflammatory medications in the treatment of common musculoskeletal inflammatory conditions: a systematic review, Iontophoretic drug delivery using the IOMED Phoresor
Physical Therapy in Its Current Form. The specific medication that is used in iontophoresis depends upon the goals of treatment. Non-invasive iontophoresis units feature high-grade medical patches that eliminate the need for hypodermic injections to receive drugs. It is often used to treat a variety of different conditions. 4, Journal of Pharmaceutical Sciences, Vol. 8, 22 July 2002 | Scandinavian Journal of Medicine & Science in Sports, Vol. [12] However, the patient must be able to comprehend and follow commands in order to actively participate in the process. 1, Annals of the New York Academy of Sciences, Vol. official website and that any information you provide is encrypted 17, No. 29, No. Iontophoresis, a type of electrical stimulation that is used to administer specific medication into your body, is a therapeutic modality commonly used in physical therapy.
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4, No. It is important that you understand the treatment goals and the medication used. Iontophoresis delivers drugs locally where they can act fast while avoiding painful and invasive needle injections. 78, No. 20, No. Fifty patients with various musculoskeletal inflammatory conditions were treated with iontophoresis (direct current 5 milliamperes, 20 minutes). Add to wishlist Delete from wishlist. 11, No. It may seem unbelievable, but tap water can also be used to treat excessive sweating in the feet or palms. 10, No. Skin Disease or Rash. system, Iontoforese/electromotive drug administration, Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain. Would you like email updates of new search results? This medication is used to treat uncontrolled muscle contractions, also known as muscle spasms. Copyright McGraw HillAll rights reserved.Your IP address is
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The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. opposed to ultrasound. This drug reduces swelling and increases mobility. Iontophoresis Iontophoresis is a technique which uses an electric current to deliver a medicine or other chemical through the skin. Unlike injectable medications which tend to peak and trough, phoresed medications can be accurately controlled and titrated over a specific period of time. It is a therapeutic modality that is used in some specialized treatment plans based on the needs of the patient. It is also contraindicated if you have a pacemaker, metal implant, cardiac arrhythmia, a skin rash, or skin disease. Establish precautions and concerns for using iontophoresis treatment. 2-3, Journal of Controlled Release, Vol. 5, 1 August 1986 | Journal of Orthopaedic & Sports Physical Therapy, Vol. MeSH Iontophoresis. The specific indications for this therapy are: A patient having an open wound. An iontophoresis patch is known for enabling a high concentration of medication to reach deeplyall the way to the muscles, with few, if any, side effects. Prentice W.E., & Quillen W, & Underwood F(Eds. Once excess ossification has been reversed, deposits can be broken down and specific exercises are performed to restore motion and function. It is one the most commonly used anti-inflammatory medications and is used in iontophoresis treatments. Iontophoresis has several advantages as a treatment technique that involves little to no patient discomfort, is a sterile, noninvasive technique for introducing specific ions into a tissue that has been demonstrated to have a positive effect on the healing process.3. 3, Medical Engineering & Physics, Vol. 7, No. Modern physical therapy has evolved quite a lot since the early days of the 20 th century. Phonophoresis is compared to iontophoresis as another means of driving a topically applied medication into the tissues, and the benefits of each are discussed. Enter your email address below and we will send you the reset instructions, If the address matches an existing account you will receive an email with instructions to reset your password, Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. 4. This div only appears when the trigger link is hovered over. 18, No. We compared the anesthetic effect of lidocaine HCL (2%) by manipulating the current parameters on 21 healthy volunteers (age: 21.2 4.2, height 170.7 10.2 cm, mass 82 . It can also be used to treat sclerotic conditions like tendonitis (break deposition of miners) or frozen shoulder. CPT - 97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes. Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: a double-blind randomized controlled trial11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Iontophoresis is a process in which electrically charged molecules or atoms (i.e., ions) are driven into tissue with an electrical field. Another study showed that iontophoresis reduced palmoplantar sweating by 81%. We offer three convenient ordering options; phone, fax or direct online ordering. It is effective, painless, and safe, and provides a viable treatment. As specific conductivity potentials were established for various chemicals and drugs, it has been shown that num Although specific statutes relative to the use of iontophoresis vary from state to state, the clinician must be aware that the majority of medications used in iontophoresis require a physician's prescription for use. As a noninvasive therapy, iontophoresis is growing in popularity among anesthesiologists, pediatricians, general and orthopedic surgeons, burn specialists, and the dental community. Latent, or skin disease Guidelines # 3 added & quot ; an injection without needle! 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