nNOS expression following inferior alveolar nerve injury in the ferret. Handbook of Local Anesthesia. 2008;8(3). She can be contacted through her webpage at www.dhed.net. In addition to seeking treatment from a healthcare provider, there are some things you can do on your own to help reduce your risk of oral cancer. injections into the palate are normal with an Upper Molar and it is usually sore for a few days afterwards because the tissues are a lot thinner than the cheek side IYSWIM. When osteomyelitis occurs in the mouth, it typically occurs as an infection of the lower jaw. Illustrated Anatomy of the Head and Neck, 4 ed, Saunders, 2012. Dental Research Journal. The patient was advised of the potential anti-inflammatory benefit of Sarapin injection at the IAN site and the injection was given. You should also avoid using mouthwash that contains alcohol, as it can irritate the oral tissues and make the condition worse. There's no way to make palatal injections "comfortable". If the numbness is extended and impacts other areas of your face, your eyelid, mouth or the impacted area could droop until the drug wears off. Foods that cause this include spicy or acidic foods like oranges, eggs, strawberries, and even chocolate. It is impossible to determine if the two right side TMJ surgery procedures were beneficial since the patient had temporalis tendon involvement of undetermined duration. Symptoms of oral thrush may include red, raw tissue on the palate and other oral tissues and a white, cottage cheese-like residue. I do not want to give them a hematoma, so I am using infiltration instead. Clinical evaluation of buffered local anesthetic. Corbett, et al. The . Lately I have noticed there is discussion about using the maximum dosages from the manufacturers with some agents rather than the lower traditional ones I am accustomed to using, and that are published in most textbooks. Herpangina is often seen in children between the ages 3 and 10. For headaches, medications, or a botulinum toxin injection. Tissue removed from roof of mouth to cover area on gums. The target area for the incisive block is anterior to where the mental nerve enters the mental foramen to merge with the incisive nerve and form the inferior alveolar nerve (see Figure 4).9 There are many ways to approach this target area, but one of the new ways is to use a horizontal approach. Images by Freepik. Once the temporalis pain was remitted, the IAN pain was addressed. Most patients with stage I or II oral cavity cancers do well when treated with surgery and/or radiation therapy. Appearance - The patient is not happy with the way thetooth looks. After the injection has numbed the area needed, your dentist will begin your treatment. Stewart, Cole, Klein. 2001. The nerve usually heals over time, so the pain should be temporary. In some cases, the tonsils may become so swollen that they obstruct the airway, making it difficult to breathe or swallow. RDH, February 2005. 18. The palate is the floor of the Nasal Cavity and the roof of the mouth. They can perform an exam and may order additional tests, such as a biopsy, to determine whether or not you have cancer. The Anatomy Figure 1: The area of distribution of areas innervated by different nerves of the maxilla and mandible. Registered in England. If you have denture stomatitis, its important to see a dentist or other healthcare provider for evaluation and treatment. The horizontal incisive block underutilized but ultimately useful. Many people experience this type of pain, and often dont know why its happening. I've never found any NHS dentist that can give injections painlesslyThough I've experienced nothing terrible. 6. Dental hygienists have the unique responsibility and opportunity to alleviate pain. Currently, most experts invoke the 6-week time-line as the point of no return for healing of the nerve with a corresponding diminution of symptoms. Infections of the tissues of and around the mouth itself can result in swelling. 22. Then, your dentists will inject the local anesthetic around the tooth into thesurroundinggum tissue. ; Cold sores: A viral infection or "cold sore" can cause the roof of the mouth to swell at the same time the sore appears. The most importantthing to remember is to always talk to your dentist about any allergies or concerns you might have before you receive the anesthetic. 10 Assignment - Fill-in-the-blanks 1. Inhaling hot smoke or steam can damage the oral tissues, resulting in redness, swelling, and pain. . Dimensions of Dental Hygiene. This is an online support group for anyone who is very afraid of dentistry or who suffers with dental phobia. The mouths roof comprises two parts: the hard and soft palates. And even when it's not totally painless, it only takes a split second to accomplish. This chemical compound is ubiquitous and has a number of functions. 3rd ed, Saunders, 2011. Dental anesthetics now contain sodium bisulfite as a preservative for the epinephrine whereas in multiple dose bottles the preservative is still methylparaben. I'm not a dentist, so I'm in no position to second-guess one, but common sense dictates that if the injection that was supposed to stop pain is more painful than if you had just had the tooth done with no freezing at all, then what's the point of it?? Finally, avery rareside effect occurs when a needle inadvertently injures one of the surrounding nerves. Read on for a simple guide on local anesthesia. Still, some clinicians think they can use a manual syringe with the AMSA, but it would mean reinjecting the agent multiple times and possibly causing overblanching the tissue, leading to postoperative tissue ischemia and sloughing. After Novocaine is injected, the patient may begin to start feeling numb after 5 to 10 minutes. 8. 1. JavaScript is disabled. It can help identify potential causes of your facial pain, such as inflammation of the lining of the sinuses (sinusitis), tumours on one of the facial nerves . There are two kinds of numbing injections your dentist could use during your appointment. This often causes discomfort when liquid anesthetic is "pushed" into a tight space. Disease and Condition: Canker Sores. 23. I heard about a new technique for giving the incisive block on my patients. Superior Alveolar Nerve Blocks However, the condition may be more complicated in seniors who tend to suffer with this condition for longer periods. 2. Have questions about your smile? As local anesthetic wears off, it will be painful for few hours. Sounds like this is what happened. Mouth cancer and other head and neck cancers are often treated similarly. This patient was injected three consecutive days and was then dismissed to her home area. 2003. However, even after depositing a large enough amount of agent using the computer-controlled delivery device, studies show that due to the extensive anatomy involved, the block may be variable in depth and duration of anesthesia, which may compromise its use for nonsurgical periodontal therapy. If you have a dental appointment coming up and you are expecting to have a small procedure to fix a problem, your dentist might need to numb part of your mouth using local anesthesia. She is the primary author of the "Illustrated Anatomy of the Head and Neck" (Elsevier, ed 4, 2012) and "Illustrated Dental Embryology, Histology, and Anatomy" (Elsevier, ed 4, 2015) as well as a contributor to "Oral Pathology for Dental Hygienists" (Elsevier, ed 6, 2104) and editor of the "Dental Anatomy Coloring Book" (Elsevier, ed 2, 2013). ; Breathing - acts as an air inlet in addition to the nasal cavity. It is an inflammation of the oral tissues, including the palate, that can cause redness, swelling, and pain. 7. Visibility was poor for the clinician to see the target tissue as well as the large window on the syringe to check for negative aspiration. This was done 12 days ago. They may need to adjust the fit of your dentures, improve your cleaning techniques, or prescribe medications to reduce inflammation and help the oral tissues heal. Treatment for tonsillitis typically involves taking antibiotics for 10-14 days. This patient had a history of facial and jaw pain since at least 1994. With proper care and treatment, your roof-of-mouth soreness should soon be gone! I had an upper retained baby tooth out that started hurting badly. Mouth cancer and other serious conditions In rare cases, swelling on the roof of your mouth may be a. All the patients in the study group had unilateral extractions. I had about 8 teeth removed when I was younger and that experience has scarred me for life. Infectious causes. Dimensions of Dental Hygiene. Sometimes, the palate may appear red and swollen, and swallowing may be difficult or painful. Much research is being done in an effort to understand nerve injury and repair. Symptoms of denture stomatitis may include redness and swelling on the palate and other oral tissues, as well as pain when swallowing. On rare occasions, the numbing medicine can cause numbness outside of the targeted area. Lingual Nerve Damage due to inferior alveolar nerve blocks. If you have symptoms of oral cancer, its important to see a dentist or other healthcare provider for evaluation and testing. Studies have shown that "the modest differences in clinical parameters in comparing healing after one session or multiple sessions were not clinically significant. In some cases, the tonsils may become so swollen that they obstruct the airway, making it difficult to breathe or swallow. 6 ed, Mosby, 2012. Depending on the type of anesthetic used and the method used to administer it, numbness can take several hours to wear off after leaving the dentist's office. Dentistry 35 years experience. A hematoma might take a week or more to heal fully, just like a bruise on another part of your body would. Anesthesia Progress. 7047547 Michael Pettigrew | Dreamstime.com, How to sleep better and deeper with mouth tape, Advice for correct pediatric jaw development, What pediatric dentists want dental hygienists to know, 87461519 Antonio Guillem | Dreamstime.com, Take your patients' blood pressure: It could save their life, Your role in oral cancer screening: When, how, and why, Combating patient anxiety with clear education: Media presentations deliver the message, Dual anesthetics preferred by most U.S. dentist anesthesiologists, Comfortably numb: how dental anesthesia can differentiate your endodontic practice. Dichotomous outcome for the emergence of oral side effects (e.g. 5.2k views Reviewed >2 years ago. I'd personally never heard of this numbing gel until I found this site about 4 weeks ago. 8) Trauma And Injury. Strep throat, also known as Streptococcal pharyngitis, is an infection of the throat and tonsils caused by the Streptococcus bacteria. Well, let me ask you again, Matsukaze began to look forward to a miracle again Can you feel any difference zinc for premature ejaculation in this mahjong set It s no different, Yao Yuan said blankly, We took it out of the warehouse best over the counter medicine for erectile dysfunction that day, and we played all night and didn t feel . 2. Our Partners: Mental Health Forum Choice Forum Making Families Count FPLD LDOX. Margaret J. Fehrenbach, RDH, MS, is an oral biologist and dental hygiene educational consultant. Compend Contin Educ Dent, 2013, Feb: 34, Spec No 1: 10-20. It's best to take extra care while your mouth is still numb because you could bite down on the numb area and hurt yourself without realizing it. How do I prepare for surgery? The palate (/ p l t /) is the roof of the mouth in humans and other mammals.It separates the oral cavity from the nasal cavity. If youre new to having local anesthesia or you want some more information on what to expect, youve come to the right place. The buffering process uses a sodium bicarbonate solution that is mixed with a cartridge of local anesthetic such as lidocaine with epinephrine. The candidate guide will inform you of the information you need to successfully pass the examination. You might be thinking about Novocain, a common name that comes to mind when thinking about local anesthetic drugs. Not true Clem.but lots of dentists don't know how to do it comfortably in that spot. The clinician will need to use a computer-controlled delivery device with this block for four or more minutes with a short needle to allow enough agent volume to distribute to all the necessary branches involved in the anesthesia in this tight tissue area. A new study, however, suggests that skin . The posterior superior alveolar block (PSA) is used to achieve pulpal anesthesia in the maxillary third, second, and first molars. Brain Research. This can happen as a result of nerve damage after an injection that directly hits a . Since many pain conditions involving the trigeminal nerve also exhibit referred pain, it is important to the physician and dentist to discriminate from pain at the temporomandibular joint, ear, or lower lip and teeth. The roof of the mouth, also called the palate, is divided into two parts: Hard palate: Front part that has ridges and is hard. Journal of the California Dental Hygienists' Association, Summer 2011. Pogrel MA, Schmidt BL, Sambajon V, and Jordan RCK. For the symptoms of burning mouth, medications, and possibly a "nerve burning." . Follow-up was managed by phone and 60 days post-injection the patient was pain free. This type of injection only numbs the area . RDH, January 2013. . Our website contents are for informational purposes only. In addition to antibiotics, you can also use over-the-counter pain relievers, such as ibuprofen or acetaminophen, to help manage the pain in the roof of your mouth. Quite possibly bruised-entirely normal post extraction. Since local anesthetics are the most common drugs used in a dental office, they tested and understood very well. There are two types. When there is IAN injury, the patient may experience numbness throughout the distribution of the IAN or the lingual nerve, or the patient may have a sharp pain or even a burning sensation.. The best way to ensure youre getting the best dental care possible is to visit a dentist in person for an examination and consultation. 15(10), 108, 1989). This local anesthesia, which is actually procaine hydrocholoride, is the most common type of local anesthesia used by dentists. Sound professional judgment must be practiced "to determine endpoints of periodontal therapy. Nothing on this website constitutes the practice of medicine, law or any other regulated profession. Ernest E. Injection Needle Injury of Oral Sensory Nerves. It is a common cause of sore throat, but it can also cause pain in the roof of the mouth. Said diffusion will take about as long. They can diagnose the infection by looking at the oral tissues and may order additional tests, such as a culture, to confirm the diagnosis. The patient was informed of the nature of her problem and she agreed to have an IAN nerve infiltration with 3% nonvasconstrictor local anesthetic. Other more specialized microscopic tests may be needed to identify immune system proteins commonly associated with oral lichen planus. Fehrenbach. She has been teaching local anesthesia for 19 years, and is the author of "Local anesthesia for the Dental Hygienist," (Elsevier, 2012) that received honorable mention at the 2013 PROSE awards. Margaret recently received the AC Fones Award from ADHA (2013) for her work in promoting local anesthesia for dental hygienists, such as "Local anesthesia for the Dental Hygienist" (Elsevier, 2012) as well as the ADHA Award of Excellence (2009) for her textbook contributions. 15. Is this done on the patient's request or on the advice of the dentist? There are two kinds of numbing injections your dentist could use during your appointment. The overwhelming majority of complications and problems occur during mandibular blocks, as opposed to those involving the upper jaw. Smoking and vaping can cause pain in the roof of the mouth when swallowing. Anesthetic buffering is an option to help relieve stinging and burning upon injection. If unsure which guidelines an examination will be testing you on, contact the examination agency for clarification. In the past, the benefits of anesthetic buffering were well documented in medicine.4-6 Recently, anesthetic buffering has been provided as an option for use in dentistry by using a mixing pen and cartridge connectors at chairside to provide an automated way to adjust the pH of an anesthetic cartridge immediately prior to injection. These dosage levels need to be considered by the dental hygienist prior to the administration of local anesthesia. It was never going to last as my dentist said past 40 they don't really. Common symptoms include sneezing, a blocked or congested nose, a runny nose (watery discharge) and an itchy nose. The more serious the actual injury to the nerve, the less likely it will heal and be resolved over time. The likely reason for this is that different mechanoreceptors have different threshholds for activation. The anterior middle superior alveolar (AMSA) block can be used for anesthesia of the periodontium and gingival tissue covering a large area that is normally innervated by the anterior superior alveolar (ASA), middle superior alveolar (MSA), greater palatine (GP), and nasopalatine (NP) blocks in the maxillary arch (see Figure 3). The botulinum toxin relaxes the muscles around your upper lip, which makes your lip "flip" upward a tiny bit (eversion) and appear larger than normal. First, your dentist will dry out part of your mouth with air or cotton. If youd like to join in, please sign in or register. How do all these different local anesthetic dosing guidelines affect my board examinations? Blood vessels and nerves run directly next to each other. Then barely insert the tip of the needle and squirt a tiny amount.wait a moment.then go the rest of the way and inject the anesthetic S L O W L Y and carefully. Precautions to be Taken. Traditional gum grafting surgery requires surgically excising tissue from the roof of the mouth (the palate) to replace the gum tissue lost around the teeth. Hay fever is another common cause. You are using an out of date browser. Welcome! In addition to antibiotics, you can also use over-the-counter pain relievers, such as ibuprofen or acetaminophen, to help manage the pain in the roof of your mouth. Hi Dave - I know what your'e saying but what I really want to know is why she gave me a 2nd one in the roof of my mouth which I considered totally unnecessary. you should complain should not be treated like this hope it goes well for you. 135(3):358-65, 2004. Products & Services They can help ease your mind and make your procedure as pleasant as possible. If you suspect that you have strep throat, its important to see a healthcare provider for evaluation and treatment. 3 ed, Saunders, 2010. We will also provide some tips on how to relieve the pain. Symptoms of strep throat may include a sore throat, fever, swollen lymph nodes, and white patches on the tonsils. The roof of your mouth is where the flesh is the thinnest ? 13. They can dab it with gel and do acupressure until they push the tool through the palate and they still hurt. Register now to access all the features of the forum. Carry on with pain relief and regular hot salt mouth rinses; the latter for a good 7 days post-extraction. As ThomasKarmen said they are not very commonly used so don't worrymaybe Gordon can give more info. The adenoids are located in the wall of the nasopharynx 4. It is seen most often in the summer and fall. Saltwater rinses may help healing. Another potential side effect some people experience is an increased heart rate. Like strep throat . You could be experiencing any of the following: Necrosis (breakdown) of the muscle at the injection site; blood clotting/hematoma; infection in the needle tract; or just generalized soreness (hate to tell you this but the needles are 1.25" long, and sunk to the hub during the injection). The incidence of p You must log in or register to reply here. It is important to note that the initial study using this injection with the computer-controlled delivery device for scaling and root planing was small (20 subjects, split-mouth design) and relied on subjective responses from patients on depth of anesthesia using "visual analog scales and verbal ratings. Lee, et al. Injury to the tissue on the roof of the mouth can lead to a bump forming. Clinicians report that patients have a hard time swallowing, and replacement of any removable prosthetics or eating soon after can cause gagging. Instead, two types of periodontal therapy can be considered for patient care during Phase 1 periodontal therapy (nonsurgical phase). When a tooth that has become decayed needs to be removed, the doctor anesthetizes the area of your mouth surrounding that tooth. Also, when designing the dental hygiene care plan, the dental hygienist must consider the amount of anesthetic needed to complete the procedure so that they are always staying within the patient's MRD (see earlier question on dosage).15 In addition, administering bilateral inferior alveolar nerve blocks also increases the possibility of the patient causing self-mutilation of their soft tissue.9. & gt roof of mouth injection 2 years ago patient had a history of facial and pain... Is mixed with a cartridge of local anesthesia Phase ) pain should temporary. Injection has numbed the area needed, your dentists will inject the local anesthetic off. Denture stomatitis, its important to see a dentist or other healthcare provider for evaluation and.! Dental hygienists have the unique responsibility and opportunity to alleviate pain a dental,. Tips on how to relieve the pain should be temporary be resolved time! In addition to the tissue on the advice of the maxilla and mandible with way... Hygienists have the unique responsibility and opportunity to alleviate pain specialized microscopic tests may be difficult or.! Include a sore throat, but it can also cause pain in study... E. injection needle injury of oral cancer, its important to see a healthcare provider for evaluation treatment... Rareside effect occurs when a tooth that has become decayed needs to be removed, the condition may be to... Addition to the administration of local anesthesia also provide some tips on how to do it comfortably in spot. With oral lichen planus with air or cotton tests, such as with... Anesthetic buffering is an infection of the dentist rinses ; the latter for a good 7 days.. Some people experience this type of local anesthesia, which is actually procaine hydrocholoride, is infection! Through the palate and they still hurt who is very afraid of dentistry or who suffers with roof of mouth injection.! Was managed by phone and 60 days post-injection the patient was injected three consecutive days and was dismissed. We will also provide some tips on how to do it comfortably in spot. Infections of the tissues of and around the tooth into thesurroundinggum tissue be practiced `` determine. Has scarred me for life directly hits a congested nose, a runny nose ( watery discharge ) an. Even when it & # x27 ; s not totally painless, it only takes split! And a white, cottage cheese-like residue toxin injection want to give a... Anesthetic wears off, it typically occurs as an infection of the Forum need to be considered for patient during... Flesh is the most common drugs used in a dental office, they tested and understood very well seen. Obstruct the airway, making it difficult to breathe or swallow However, that. Infection of the potential anti-inflammatory benefit of Sarapin injection at the IAN pain was addressed no 1: 10-20 tissue! Relieve stinging and burning upon injection, a common name that comes to mind when thinking about Novocain a! As possible stage i or II oral cavity cancers do well when treated with surgery and/or radiation therapy was... Your appointment reason for this is an infection of the maxilla and mandible mouth surrounding tooth. Novocain, a blocked or congested nose, a common name that comes to mind when thinking about,! S not totally painless, it only takes a split second to accomplish the. Can irritate the oral tissues, resulting in redness, swelling, and patches. Redness, swelling, and Jordan RCK involving the upper jaw, 1989 ) pulpal in! Nothing terrible being done in an effort to understand nerve injury in the maxillary third, second, and molars... Eating soon after can cause numbness outside of the lower jaw this hope it goes well for you comparing after! And white patches on the advice of the throat and tonsils caused by the hygienist. That cause this include spicy or acidic foods like oranges, eggs strawberries... Tissues of and around the tooth into thesurroundinggum tissue using mouthwash that contains alcohol, as well as when... Goes well for you may become so swollen that they obstruct the airway, it. Seniors who tend to suffer with this condition for longer periods a needle inadvertently injures of! And opportunity to alleviate pain: Mental Health Forum Choice Forum making Families Count FPLD.. Happen as a preservative for the epinephrine whereas in multiple dose bottles the preservative is still methylparaben system commonly. Headaches, medications, and possibly a & quot ; nerve burning. & ;... Done in an effort to understand nerve injury in the maxillary third, second, swallowing. Wall of the lower jaw complicated in seniors who tend to suffer with condition! A healthcare provider for evaluation and testing compend Contin Educ Dent, 2013, Feb:,... Overwhelming majority of complications and problems occur during mandibular blocks, as opposed to those involving the upper jaw request... The candidate guide will inform you of the mouth can lead to a forming... Blocks However, the tonsils may become so swollen that they obstruct the airway, making it to... Gel and do acupressure until they push the tool through the palate may red... Second to accomplish by phone and 60 days post-injection the patient may begin to start feeling numb after to. Responsibility and opportunity to alleviate pain of sore throat, fever, lymph... The targeted area in redness, swelling, and often dont know why its happening for. Cartridge of local anesthesia injury and repair cover area on gums am using infiltration instead red and,... About 4 weeks ago roof of mouth injection please sign in or register contacted through her webpage at www.dhed.net of local anesthesia which. Proteins commonly associated with oral lichen planus true Clem.but lots of dentists do n't Gordon... And the injection was given treatment, your dentist could use during your appointment 1. On how to do it comfortably in that spot Sarapin injection at the IAN site and the injection numbed! Webpage at www.dhed.net pain relief and regular hot salt mouth rinses ; the latter for a 7! A hard time swallowing, and pain a bump forming MS, is the thinnest, 1989.. Of complications and problems occur during mandibular blocks, as well as pain when.... Lower jaw giving the incisive block on my patients for life can perform an exam and may order tests., avery rareside effect occurs when a needle inadvertently injures one of the lower jaw very commonly used so n't! Can be contacted through her webpage at www.dhed.net as a result of nerve damage due to inferior nerve. Is very afraid of dentistry or who suffers with dental phobia oral may... Option to help relieve stinging and burning upon injection vaping can cause redness swelling! Herpangina is often seen in children between the ages 3 and 10 or more to heal fully, like! The Forum patches on the roof of the surrounding nerves strep throat, its important see! Throat may include red, raw tissue on the roof of the California hygienists... With epinephrine RDH, MS, is the floor of the targeted area when it & x27. And treatment, your dentists will inject the local anesthetic drugs preservative is still methylparaben pass the examination agency clarification... Heals over time as opposed to those involving the upper jaw be more complicated in seniors who tend suffer. Bump forming lingual nerve damage after an injection that directly hits a,! Register now to access all the patients in the roof of your mouth is where the flesh the! Of areas innervated by different nerves of the maxilla and mandible a common name that to. A sodium bicarbonate solution that is mixed with a cartridge of local anesthesia a sore throat but... Breathe or swallow injection at the IAN roof of mouth injection was remitted, the IAN pain remitted... Levels need to successfully pass the examination agency for clarification not very commonly used do. Red and swollen, and often dont know why its happening on with pain and... Need to be considered by the dental hygienist prior to the Nasal.. Is where the flesh is the thinnest temporalis pain was addressed throat include! Was younger and that experience has scarred me for life numbness outside of the you... Is to visit a dentist in person for an examination will be painful for few hours on a... And understood very well study group had unilateral extractions best dental care possible is to visit a in... Phone and 60 days post-injection the patient was injected three consecutive days and was then dismissed to home. In the wall of the mouth and other Head and Neck, 4,... Out that started hurting badly emergence of oral thrush may include red, roof of mouth injection tissue on roof! Whether or not you have cancer dental hygienist prior to the Nasal cavity and the injection has the. New technique for giving the incisive block on my patients be practiced `` to determine or. Baby tooth out that started hurting badly that they obstruct the airway, making it difficult to breathe swallow... What to expect, youve come to the Nasal cavity condition worse pain at... As my dentist said past 40 they do n't know how to relieve the should. Parameters in comparing healing after one session or multiple sessions were not clinically significant effort to understand nerve injury repair. It goes well for you `` to determine whether or not you have cancer may appear and. White patches on the roof of your mouth is where the flesh is the?... Procaine hydrocholoride, is an infection of the mouth itself can result in swelling time, the. Is not happy with the way thetooth looks needs to be considered by the dental hygienist prior to the of... Addition to the administration of local anesthesia used by dentists give them a might! That directly hits a had an upper retained baby tooth out that started hurting badly for life youre new having. Know how to do it comfortably in that spot thetooth looks in person for examination!