Does Liposomal Bupivacaine (Exparel) Significantly Reduce Postoperative Pain/Numbness in Symptomatic Teeth with a Diagnosis of Necrosis? A Prospective, Randomized, Double-blind Trial

May carriers at nanoscale improve the Endodontic's future?

Nanocarriers (NCs) are dynamic nanovehicles used to transport bioactive derivatives like therapeutical formulations, drugs and/or dyes. The current review assists in understanding the mechanism of action of several recent developed NCs with antimicrobial purposes. Here, nine NCs varieties are portrayed with focus on nineteen approaches that are fulfil described based on outcomes obtained from in vitro antimicrobial assays. All approaches have previously been verified and we underline the biochemical challenges of all NCs, expecting that the present data may encourage the application of NCs in endodontic antimicrobial basic research. Methodological limitations and the evident base gaps made not possible to draw a definite conclusion about the best NCs for achieving efficient antimicrobial outcomes in endodontic studies. Due to the lack of pre-clinical trials and the scarce number of clinical trials in this emergent area, there is still much room for improvement on several fronts.

Liposomal Bupivacaine in Dentistry and Oral and Maxillofacial Surgery. A Review of Human and Veterinary Literature

This article reviews the human and veterinary literature regarding liposome encapsulated bupivacaine use in dentistry and oral and maxillofacial surgery. The purpose of this review is to present available information on this local anesthetic in a manner that will allow veterinary dentists and oral and maxillofacial surgeons to use evidence-based information when considering incorporating liposomal bupivacaine into their practice. The twelve human clinical studies and three veterinary reports that met the literature search criteria do not support the use of liposomal bupivacaine in veterinary dentistry and oral and maxillofacial surgery.

Nanoparticles in Dentistry: A Comprehensive Review

In recent years, nanoparticles (NPs) have been receiving more attention in dentistry. Their advantageous physicochemical and biological properties can improve the diagnosis, prevention, and treatment of numerous oral diseases, including dental caries, periodontal diseases, pulp and periapical lesions, oral candidiasis, denture stomatitis, hyposalivation, and head, neck, and oral cancer. NPs can also enhance the mechanical and microbiological properties of dental prostheses and implants and can be used to improve drug delivery through the oral mucosa. This paper reviewed studies from 2015 to 2020 and summarized the potential applications of different types of NPs in the many fields of dentistry.

Overcoming barriers by local drug delivery with liposomes

Localized or topical administration of drugs may be considered as a potential approach for overcoming the problems caused by the various biological barriers encountered in drug delivery. The combination of using localized administration routes and delivering drugs in nanoparticulate formulations, such as liposomes, may have additional advantages. Such advantages include prolonged retention of high drug loads at the site of action and controlled release of the drug, ensuring prolonged therapeutic effect; decreased potential for side-effects and toxicity (due to the high topical concentrations of drugs); and increased protection of drugs from possible harsh environments at the site of action. The use of targeted liposomal formulations may further potentiate any acquired therapeutic advantages. In this review we present the most advanced cases of localized delivery of liposomal formulations of drugs, which have been investigated pre-clinically and clinically in the last ten years, together with the reported therapeutic advantages, in each case.

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.

The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochloride for the prevention of postoperative pain: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND/IMPORTANCE

Liposomal bupivacaine (LB) is a prolonged release formulation of conventional bupivacaine designed for prolonging local or peripheral regional single injection anesthesia. To this day, the benefit of the new substance on relevant end points is discussed controversial.

OBJECTIVE

The objective was to determine whether there is a difference in postoperative pain scores and morphine consumption between patients treated with LB and bupivacaine hydrochloride in a systematic review and meta-analysis.

EVIDENCE REVIEW

Randomized controlled trials (RCT) were identified in Embase, CENTRAL, MEDLINE and Web of Science up to May 2020. Risk of bias was assessed using Cochrane methodology. Primary end points were the mean pain score difference and the relative morphine equivalent (MEQ) consumption expressed as the ratio of means (ROM) 24 and 72 hours postoperatively.

FINDINGS

23 RCTs including 1867 patients were eligible for meta-analysis. The mean pain score difference at 24 hours postoperatively was significantly lower in the LB group, at -0.37 (95% CI -0.56 to -0.19). The relative MEQ consumption after 24 hours was also significantly lower in the LB group, at 0.85 (0.82 to 0.89). At 72 hours, the pain score difference was not significant at -0.25 (-0.71 to 0.20) and the MEQ ratio was 0.85 (0.77 to 0.95).

CONCLUSION

The beneficial effect on pain scores and opioid consumption was small but not clinically relevant, despite statistical significance. The effect was stable among all studies, indicating that it is independent of the application modality.

Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia

BACKGROUND

Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics.

METHODS

The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h.

RESULTS

Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported.

CONCLUSIONS

Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.

EDITOR’S PERSPECTIVE

Local anaesthesia in dentistry: a review

Over the past century, there is perhaps no greater contribution to the practice of clinical dentistry than the development and application of local anaesthesia. What were once considered painful procedures have now been made routine by the deposition and action of local anaesthetics. This article will serve as a review of basic pharmacological principles of local anaesthesia, subsequent sequelae that can arise from their use, considerations when using local anaesthetics, and recent advances in the delivery of local anaesthetics.

Evaluation of the Efficacy of Liposomal Bupivacaine in Total Joint Arthroplasty

BACKGROUND

Appropriate pain control is one of the cornerstones necessary to promote positive clinical outcomes. A new bupivacaine liposomal formulation was designed to extend its analgesic effect for up to 72-hours post-surgery, reportedly leading to significant opioid-sparing.

METHOD

Retrospective and prospective chart review conducted in a 178-bed academic institution between January 2013 to December 2013 and August 2014 to November 2014, in 115 patients that receive hip and knee arthroplasty. The primary outcome was the measurement of average daily pain score on post-operative days 1 and 2. Secondary outcomes included length of stay, overall opioid use post-surgery and pain control satisfaction using Press-Ganey® scores.

RESULTS

The average pain scores in the HCl group were 4.64 and 4.38 (Likert score: 0-10) for POD 1 and POD 2, compared to 4.72 POD 1 and 4.2 POD 2 in the liposome group (POD 1: p = 0.413; POD 2: p = 0.303). The difference in LOS for knee arthroplasty was statistically significant [HCl group: 1.94 days (± 0.66) versus liposome group: 2.27 days (±0.77) p-value = 0.038)] favoring the standard of care. For hip arthroplasty or bilateral knee arthroplasty the differences in LOS were not statistically significant (p = 0.052 and p = 0.484 respectively). 93% of the patients in the HCl group, pain was well controlled, versus 88.5% in the liposome group with similar oxycodone IR use among groups.

CONCLUSION

Liposome bupivacaine did not offer a notable benefit compared to the HCl formulation in our study.

Efficacy of dental local anesthetics: A review

The objective of this review was to investigate the efficacy of dental local anesthetics, as it is well known among clinicians that local anesthesia may be challenging in some circumstances. Therefore, the focus of this review was on the efficacy of the products used in dental local anesthesia.

In a Pubmed database literature search conducted, a total of 8646 articles were found to be related to dental local anesthetics. After having applied the inclusion criteria (human research, performed in the last 10 years, written in English language, and focus on dental local anesthetics) and having assessed the quality of the papers, 30 were deemed eligible for inclusion in this review.

The conclusion of this review is that none of the dental local anesthetic amides provide 100% anesthesia. The problem appears to be more pronounced when mandibular teeth are attempted to be anaesthetized and especially if there is irreversible pulpitis involved. The authors conclude that this finding suggest exploration of more efficient techniques to administer dental local anesthesia, especially in the mandible, to establish a 100% efficacy, is needed.

Pain Reduction in Untreated Symptomatic Irreversible Pulpitis Using Liposomal Bupivacaine (Exparel): A Prospective, Randomized, Double-blind Trial

INTRODUCTION

In the treatment of patients with symptomatic irreversible pulpitis, endodontic debridement is a predictable method to relieve pain. However, there are clinical situations in which emergency care cannot be provided immediately. An unexplored treatment option in these cases may be the use of a long-acting anesthetic to reduce pain in untreated irreversible pulpitis. Some medical studies have shown potential for infiltrations of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, San Diego, CA) to prolong pain relief and reduce opioid use postoperatively. The Food and Drug Administration has approved Exparel only for infiltrations; therefore, the purpose of this study was to compare an infiltration of liposomal bupivacaine versus bupivacaine for pain control in untreated, symptomatic irreversible pulpitis.

METHODS

Ninety-five emergency patients received 2% lidocaine with 1:100,000 epinephrine via infiltration or an inferior alveolar nerve block to relieve their initial presenting pain. Patients then randomly received either 4 mL liposomal bupivacaine (13.3 mg/mL) or 4 mL 0.5% bupivacaine with 1:200,000 epinephrine by infiltration. Patients received a diary for the day of the appointment and 3 days postinjection to record soft tissue numbness, pain levels, and analgesic (non-narcotic and narcotic) use.

RESULTS

No significant differences (P < .05) were found between the 2 anesthetic formulations for pain or the use of pain medications. A statistically higher level of soft tissue numbness was found on days 1 to 3 for the liposomal bupivacaine group.

CONCLUSIONS

Although liposomal bupivacaine had some effect on soft tissue anesthesia, it did not reduce pain to manageable clinical levels in patients presenting with untreated, symptomatic irreversible pulpitis.