Title Local Administration of Bupivacaine May Prove Effective in Reducing Post-operative Pain
Clinical Question In patients undergoing periodontal surgery, is local administration of Bupivacaine effective in reducing post-operative pain?
Clinical Bottom Line For patients undergoing periodontal surgery, local administration of Bupivacaine may be effective in reducing post-operative pain. This is suggested by two systematic reviews showing a significant reduction of post-operative pain with local infiltration of Bupivacaine according to patient VAS scores. Further research applying this treatment to periodontal surgery specifically is needed before determining external validity and applicability.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
32550728Jiang/202018 RCTs, 1308 participantsMeta-Analysis
Key resultsFollowing local infiltration with Bupivacaine, 7 studies showed a significant reduction of pain according to the postoperative pain scale at 1 hour (P<0.05) and rescue analgesic requirement (OR: 0.36, P<0.05). Heterogeneity was measured via I^2=79% indicating significant heterogeneity. Compared with bilateral superficial cervical plexus block, local infiltration with bupivacaine provides a better effect in terms of postoperative analgesia (P<0.05).
27673545Vyas/20168 articles, 405 participantsSystematic review of non-randomized trials
Key resultsTwo studies reported over 80% of patients were “extremely satisfied” with their pain management using Bupivicaine (Feierman 2014; Smoot 2012). In addition, when comparing liposomal bupivacaine to bupivacaine hydrochloride, there was no difference found in pain reduction from 0 to 72 hours (Smoot 2012). A third study reported that 97% of patients would want liposomal bupivacaine again if additional surgery was needed (Eberle 2015). No studies reported any serious adverse events. High heterogeneity and the low quantity and quality of evidence created limitations in the authors’ confidence in the effect, stating further research is needed.
11012656El-Hakim/202092 patients undergoing tonsillectomyRandomized Controlled Trial
Key results92 patients undergoing tonsillectomy were randomized into three treatment groups and evaluated for post-operative pain levels. In the bupivicaine, saline, and no injection groups, the mean postoperative pain scores for the full post-operative period studied were 2.1 (SD, 0.8), 1.9 (SD, 0.7) and 1.9 (SD, 0.7), respectively. Pain scores at 16-24 hours post-operatively showed a mean value of 2.4 (SD, 1.1) for the bupivacaine group, as opposed to values of 1.8 (SD, 0.8) in the saline and 1.6 (SD, 0.7) in the no injection group (P<0.001). 0.5% bupivacaine injections were not effective in reducing post-operative pain.
Evidence Search ("bupivacain"[All Fields] OR "bupivacaine"[MeSH Terms] OR "bupivacaine"[All Fields] OR "bupivacaine s"[All Fields] OR ("bupivacain"[All Fields] OR "bupivacaine"[MeSH Terms] OR "bupivacaine"[All Fields] OR "marcain"[All Fields] OR "marcaine"[All Fields] OR "bupivacaine s"[All Fields])) AND ("pain, postoperative"[MeSH Terms] OR ("pain"[All Fields] AND "postoperative"[All Fields]) OR "postoperative pain"[All Fields] OR ("postoperative"[All Fields] AND "pain"[All Fields]) OR ("pain, postoperative"[MeSH Terms] OR ("pain"[All Fields] AND "postoperative"[All Fields]) OR "postoperative pain"[All Fields] OR ("post"[All Fields] AND "operative"[All Fields] AND "pain"[All Fields]) OR "post operative pain"[All Fields]))
Comments on
The Evidence
Although Jiang’s meta-analysis provided preliminary data that local infiltration of Bupivacaine reduced post-operative pain and reduced the rescue analgesic requirement, its validity is limited by the high heterogeneity (I^2=79%), and small sample size. Vyas’s systematic review failed to provide heterogeneity scores, and indicated that “several studies reported a small sample size…and one RCT was both underpowered and terminated early.” Although El—Hakim’s RCT was appropriately blinded and reported an appropriate sample size, limitations include reporting bias and lack of statistical significance. Overall, there is a vast heterogeneity of studies included, in both sample populations and study design. Preliminary results indicate the administration of local Bupivacaine may have analgesic benefits, but further research in a more controlled and standardized setting is needed before determining external validity.
Applicability Utilizing bupivacaine as an adjunct to reduce post-operative pain in dental procedures is warranted and has no recorded adverse outcomes in a wide demographic of patients and procedures. Although limited data is available regarding its use in dental procedures specifically, the low cost and high availability, as well as high familiarity and ease of use certainly warrants further investigation into its effectiveness in the dental setting. In alignment with the ADA’s values and mission statement, the desire to reduce post-operative pain and increase patient comfort substantiates the applicability of bupivacaine administration.
Specialty (Oral Medicine/Pathology/Radiology) (Endodontics) (General Dentistry) (Oral Surgery) (Periodontics) (Restorative Dentistry)
Keywords Bupivacaine, Post-operative pain, Marcaine
ID# 3499
Date of submission 12/01/2022
E-mail kosterj@uthscsa.edu
Author Jessica Koster, DDS
Co-author(s) Marco Irimia, DMD
Co-author(s) e-mail irimia@livemail.uthscsa.edu
Faculty mentor Dr. Angela Palaiologou, DDS, MS
Faculty mentor 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?)
None available
Comments and Evidence-Based Updates on the CAT
None available