Double-blind, randomized controlled clinical trial on analgesic efficacy of local anesthetics articaine and bupivacaine after impacted third molar extraction

Post-Procedure Analgesic Management

During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.

Injectable and topical local anesthetics for acute dental pain: 2 systematic reviews

BACKGROUND

Local anesthesia is essential for pain control in dentistry. The authors assessed the comparative effect of local anesthetics on acute dental pain after tooth extraction and in patients with symptomatic irreversible pulpitis.

TYPES OF STUDIES REVIEWED

The authors searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the US Clinical Trials registry through November 21, 2020. The authors included randomized controlled trials (RCTs) comparing long- vs short-acting injectable anesthetics to reduce pain after tooth extraction (systematic review 1) and evaluated the effect of topical anesthetics in patients with symptomatic pulpitis (systematic review 2). Pairs of reviewers screened articles, abstracted data, and assessed risk of bias using a modified version of the Cochrane risk of bias 2.0 tool. The authors assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Fourteen RCTs comparing long- vs short-acting local anesthetics suggest that bupivacaine may decrease the use of rescue analgesia and may not result in additional adverse effects (low certainty evidence). Bupivacaine probably reduces the amount of analgesic consumption compared with lidocaine with epinephrine (mean difference, -1.91 doses; 95% CI, -3.35 to -0.46; moderate certainty) and mepivacaine (mean difference, -1.58 doses; 95% CI, -2.21 to -0.95; moderate certainty). Five RCTs suggest that both benzocaine 10% and 20% may increase the number of people experiencing pain reduction compared with placebo when managing acute irreversible pulpitis (low certainty).

PRACTICAL IMPLICATIONS

Bupivacaine may be superior to lidocaine with epinephrine and mepivacaine with regard to time to and amount of analgesic consumption. Benzocaine may be superior to placebo in reducing pain for 20 through 30 minutes after application.

Comparison of the effects of articaine and bupivacaine in impacted mandibular third molar tooth surgery: a randomized, controlled trial

Background

The aim of this randomized, triple-blind trial was to determine the anesthetic, analgesic, and hemodynamic effects of articaine and bupivacaine in the extraction of impacted mandibular third molar teeth.

Methods

Twenty-six patients who underwent removal of bilaterally symmetric mandibular third molars were randomly assigned to articaine and bupivacaine groups in a split-mouth design. The onset of anesthetic action, intraoperative comfort, total amount of solution used, duration of postoperative anesthesia and analgesia, rescue analgesic use, postoperative pain, intraoperative bleeding, and hemodynamic parameters were evaluated.

Results

In the articaine group, the onset of anesthetic activity was faster, intraoperative comfort was greater, and effective anesthesia required less local anesthetic solution. The bupivacaine group showed a significantly longer duration of postoperative anesthesia and analgesia, in addition to lower visual analog scale values at 6 and 48 hours postoperatively. There were no significant differences between the two solutions regarding rescue analgesic medication use, intraoperative bleeding, or hemodynamics.

Conclusion

Articaine showed greater clinical efficacy than bupivacaine in intraoperative anesthesia, achieving faster onset of anesthetic action and greater patient comfort while also requiring less reinforcement during surgery. However, bupivacaine was superior in terms of postoperative anesthesia, reducing postoperative pain due to its residual anesthetic and analgesic effects. Both anesthetic solutions led to similar hemodynamics at low doses in mandibular third molar surgery.

Pharmacological and Non-Pharmacological Methods of Postoperative Pain Control Following Oral and Maxillofacial Surgery: A Scoping Review

PURPOSE

To conduct a scoping review regarding current pharmacological and non-pharmacological methods of postoperative pain control following oral and maxillofacial surgery.

MATERIALS AND METHODS

PubMed was used to conduct research for this study. Identification criteria included surgery: patients undergoing the extraction of third molars; therapy: pharmacological or non-pharmacological methods; and outcomes: postoperative pain control. The search included full-text RCTs published after October 13, 2014, that were electronically accessible on PubMed and in the English language. After assessing quality, a scoping review was performed.

RESULTS

Thirty-five RCTs were evaluated, which included a total of 3,791 subjects. The studies evaluated patients' postoperative pain by either utilizing a visual analogue scale (VAS), measuring the time between surgery and when rescue analgesics were used, measuring the amount of rescue analgesics used, or by distributing questionnaires.

CONCLUSION

COX-2 inhibitors may provide greater analgesic effects compared to traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Additionally, although the supplementation of an opioid analgesic to a NSAID regimen provides an increase in pain control, it does not further reduce pain levels in a patient alternating between ibuprofen and acetaminophen. Other methods of postoperative pain control mentioned in this review should be further explored in studies that contain larger sample sizes and that evaluate side effects of the treatment.

Safety and efficacy of 4% articaine in mandibular third-molar extraction: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The authors aimed to assess whether 4% articaine is a safe and effective local anesthetic (LA) for mandibular third-molar extractions.

TYPES OF STUDIES REVIEWED

The authors searched MEDLINE (PubMed), Cochrane Library, Scopus, and Web of Science databases to identify randomized clinical trials that fulfilled the eligibility criteria. Risk of bias was evaluated using the Cochrane risk-of-bias assessment tool. The authors performed a meta-analysis of safety and efficacy variables comparing 4% articaine with different LAs.

RESULTS

The authors assessed 482 articles but only 14 randomized clinical trials met the inclusion criteria for review. No statistically significant differences were found among the selected LAs regarding safety. Four percent articaine required fewer reinjections than 2% lidocaine and had a shorter onset time than 2% lidocaine, 0.5% bupivacaine, and 4% lidocaine. Four percent articaine had a longer anesthesia effect than 2% lidocaine and 2% mepivacaine, but a shorter anesthesia effect than 0.5% bupivacaine.

PRACTICAL IMPLICATIONS

Use of 4% articaine for mandibular third-molar extraction is a safe choice that requires fewer reinjections and has a shorter onset time than other aminoamide-type LAs.

Effectiveness of anesthetic solutions for pain control in lower third molar extraction surgeries: a systematic review of randomized clinical trials with network meta-analysis

OBJECTIVE

To assess the effectiveness of different anesthetic solutions for pain control immediately after the extraction of lower third molars.

METHODS

Nine databases were used to identify randomized clinical trials, without restriction of language or year of publication. The "JBI Critical Appraisal Tools for Systematic Reviews" was used to assess the risk of bias in the studies. The network meta-analysis was performed to compare the effectiveness of different anesthetics to control the pain immediately after the surgery of lower third molars, using the standardized mean difference (SMD) as the effect estimate. The GRADE approach was used to assess the certainty of evidence.

RESULTS

The search presented 13,739 initial results, from which 45 met the eligibility criteria and presented low to moderate risk of bias. Thirteen studies were included in the meta-analysis. The 2% lidocaine + clonidine presented the lowest pain scores (SMD = - 1.44; - 2.72 to - 0.16) compared to 4% articaine + adrenaline, followed by 0.5% bupivacaine + adrenaline (SMD = - 1.36; - 2.13 to - 0.59). The certainty of evidence varied between very low to moderate.

CONCLUSION

2% lidocaine + clonidine and 0.5% bupivacaine + adrenaline were the anesthetics with the highest probability for pain control immediately after the surgical procedure of removing impacted lower third molars.

CLINICAL SIGNIFICANCE

The use of an adequate anesthetic with effective pain control can contribute to a more comfortable postoperative period.