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| Title |
Liposomal Bupivacaine May Reduce Postoperative Pain Following Dental Surgeries |
| Clinical Question |
In patients undergoing dental surgery, does liposomal bupivacaine compared to an active placebo or control offer superior pain management? |
| Clinical Bottom Line |
For patients undergoing dental surgery, administration of liposomal bupivacaine might have beneficial effects on postoperative pain control. However, there are mixed results for efficacy in pain reduction of liposomal bupivacaine compared to placebo or active ingredient controls for dental surgeries. Thus, no conclusion can currently be made. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 36855302 | Kellner/2023 | 12 clinical studies, 3 veterinary case reports | Literature review including animal studies | | Key results | There are varying results amongst the human studies that evaluate the use of liposomal bupivacaine for pain control in dental procedures. Six studies showed no significant reduction in pain associated with liposomal bupivacaine, three studies showed significant pain reduction associated with liposomal bupivacaine, four studies showed a statistically significant reduction in postoperative opioid use associated with use of liposomal bupivacaine, and seven studies found no significant reduction in postoperative opioid use associated with liposomal bupivacaine. There were no clinical studies published in veterinary literature regarding liposomal bupivacaine use for dental procedures, but reports on its clinical use question the benefit versus risk of longer postoperative anesthesia. | | #2) 33862580 | Ji/2021 | 63 RCTs, 6770 total subjects | Systematic review of randomized trials | | Key results | Compared to placebo or active ingredient controls, liposomal bupivacaine did not demonstrate significant pain relief reduction in 74.5% of the assessed RCTs. When assessing pain relief of some of the surgical specialties, 2 of 20 orthopedic surgery knee arthroplasty, 2 of 3 OBGYN hysterectomy, 2 of 5 general surgery colorectal or small bowel resection, and 3 of 4 dental procedure studies resulted in pain relief with liposomal bupivacaine compared to the studied control. There was no significant reduction in postoperative opioid use overall, reported in 85.71% of the reviewed studies. | | #3) 36243034 | James/2023 | 24 patients undergoing 3rd molar extractions | Randomized Controlled Trial | | Key results | 24 patients requiring extraction of third molars were randomly assigned into two treatment groups, infiltration with 0.5% bupivacaine (control) or liposomal bupivacaine (experimental). Postoperative pain and narcotic use were assessed following treatment. At 48 hours postoperative, there was no statistical difference in pain levels between the experimental and control groups. Postoperative interview pain results using a visual analog scale ranged from 0-10 in the control and 0-7 in the experimental group at 48 hours, as well as 0-4 in both groups 1 week postsurgery. When adjusting for pain at 48 hours, a significant difference was detected between the control and liposomal bupivacaine group at 1 week follow-up (adjusted means 1.8 and 0.5, P=0.037), suggesting a slight benefit in pain control with liposomal bupivacaine. No significant difference was found between groups when evaluating the number of narcotics taken postoperatively. | | #4) 36855302 | Lieblich/2021 | 600 adults who had at least one partially or fully impacted mandibular third molar extracted | Retrospective Cross-Sectional Study | | Key results | The group given liposomal bupivacaine were prescribed 59% less total opioids (47.1 morphine milligrams equivalents vs. 113.8 morphine milligrams equivalents; p < 0.0001) than the non-liposomal bupivacaine group after extraction of third molars, even after adjusting for age, sex, anesthesia type, ASA classification, and surgical complications (44.9 vs 109.5; p<0.0001). Additionally, subjects who were given liposomal bupivacaine had 4.4% less opioid prescription refill rate (3.3% vs 7.7%) with an odds ratio of 0.38 (p=0.28). | |
| Evidence Search |
“Liposomal Bupivacaine” AND “Dentistry” |
Comments on
The Evidence |
The Kellner literature review evaluates studies which found inconsistent results regarding the clinical relevance of using liposomal bupivacaine. 41.6% of the studies found no significant difference with the use of liposomal bupivacaine, and 25% found the benefits limited to 24 hours after the procedure. Overall, the review was inconclusive and further research is necessary comparing more specific clinical variables to draw a conclusion. There was no clear method shown for inclusion of the articles reviewed and the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were not followed.
In the Ji et al. systematic literature review in the MEDLINE/PubMED and Cochrane Review databases, 6770 total subjects from sixty-three articles were included. Publication bias must be considered, since nearly half (47.17% ) of the registered RCTs on ClinicalTrials.gov were unpublished and not available for readers. Thus, the overall impact of liposomal bupivacaine might not be seen in these results. The authors also reported that when manufacturers were funding the studies, results favored liposomal bupivacaine reducing pain and postoperative opioid use. No meta-analysis was performed due to heterogeneity among the studies involving different specialties, procedures, and peri-operative protocols. In addition, the authors discuss that on a study level, many of the RCTs published were of low quality. Thus, overall, on the study and systematic review levels, there was low quality evidence.
James conducted a randomized clinical trial between November 2018 to June 2022. The recruited participants were randomized into either the experimental or control groups. The authors planned to achieve 80% power, which would require n=26, with 13 participants in both study groups. However, due to dropout, there were only 12 participants in each group, resulting in underpowered results. Also, different providers were used for the treatments.
Lieblich retrospectively evaluated records at two different outpatient surgery centers. At one of the surgery centers, procedures with and without liposomal bupivacaine were performed 6 years apart. Changes in federal regulations regarding prescribing opioids and changes in surgical protocol between 2012 and 2018 are potential sources of bias in measuring the outcome of use of postoperative morphine milligram equivalents. There was no standard initial opioid prescription written for subjects of the study, the amount of opioids prescribed was a clinical decision made for each subject. Due to the retrospective approach, assumptions were made that subjects had taken all of the opioids prescribed originally if there was a call for a refill, and that they were still in pain. The student only evaluated clinical cases at two different clinics. |
| Applicability |
The use of liposomal bupivacaine could potentially be beneficial for dental procedures in reducing postoperative pain. More research is needed to support if liposomal bupivacaine is a better alternative for postoperative pain control compared to other regularly used local anesthetics. For dental procedures that do not usually require postoperative pain management prescriptions other than over-the-counter medications, liposomal bupivacaine may not be indicated. However, for procedures that generally warrant a postoperative prescription such as an opioid, using liposomal bupivacaine may decrease the need for prescribing a controlled substance. Liposomal bupivacaine is more expensive, requires refrigeration, and is not currently available in single use doses in small amounts to be used for dental procedures. Thus, the expense and waste of liposomal bupivacaine might hinder clinical use. In addition, there are no current studies assessing the use of liposomal bupivacaine in periodontal literature and future research could be warranted to assess postoperative pain control following flap surgeries. Nevertheless, liposomal bupivacaine was not found to have adverse effects and could potentially result in reduction in pain following dental procedures. |
| Specialty/Discipline |
(Endodontics) (General Dentistry) (Oral Surgery) (Periodontics) (Restorative Dentistry) |
| Keywords |
Postoperative pain, Liposomal bupivacaine, Marcaine, Bupvacaine, Dental Surgery
|
| ID# |
3570 |
| Date of submission: |
10/22/2024 |
| E-mail |
schaeffer@uthscsa.edu |
| Author |
Danielle Schaeffer, DDS |
| Co-author(s) |
Robert Wuo, DDS |
| Co-author(s) e-mail |
wuo@uthscsa.edu |
| Faculty mentor/Co-author |
Dr. Angela Palaiologou, DDS, MS |
| Faculty mentor/Co-author e-mail |
PalaiologouA@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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