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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 4  |  Page : 81-83

Bupivacaine for surgical removal of impacted mandibular third molar: A comparative evaluation with lignocaine


1 Department of Oral and Maxillofacial Surgery, Patna Dental College and Hospital, Patna, Bihar, India
2 Department of Oral and Maxillofacial Surgery, Rajarajeswari Dental College and Hospital, Bengaluru, Karnataka, India
3 Department of Dentistry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, Sikkim, India
4 Department of Oral Medicine and Radiology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

Date of Submission29-Oct-2019
Date of Acceptance02-Nov-2019
Date of Web Publication19-Nov-2019

Correspondence Address:
Dr. Sandeep Kashyap
Department of Dentistry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, Sikkim.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_36_19

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  Abstract 

Background: Removal of impacted molar teeth is the most frequent oral surgical procedure often followed by mild to severe postoperative pain, and it has a significant impact on the patient’s postoperative quality of life. The use of long-acting local anesthetics is a promising strategy to improve postoperative analgesia. The study aimed to compare the efficacy of bupivacaine with that of lignocaine, which has already proven its efficacy. Materials and Methods: The study was conducted on 50 subjects requiring the surgical removal of impacted mandibular molar teeth. A total of 25 subjects received 2% lignocaine with 1:80,000 adrenaline, whereas the remaining 25 received 0.5% bupivacaine with 1:200,000 adrenaline. The time of onset of action and duration of anesthesia were recorded. The intensity of postoperative pain was determined using the visual analog scale. The data obtained were statistically analyzed. Results: The mean time of onset of action was 2.5min and 5min for lignocaine and bupivacaine, respectively. The longer duration of action and lesser pain intensity were observed with bupivacaine, which was statistically significant. Conclusion: Bupivacaine provides better and prolonged anesthesia and analgesia postoperative to surgical removal of the impacted mandibular third molar. Hence, the use of bupivacaine in the surgical removal of the impacted third molar is desirable.

Keywords: Bupivacaine, impacted third molar, lignocaine, local anesthesia


How to cite this article:
Haidry N, Ranganatha N, Raj R, Kashyap S, Kumar A, Singh A. Bupivacaine for surgical removal of impacted mandibular third molar: A comparative evaluation with lignocaine. Int J Oral Care Res 2019;7:81-3

How to cite this URL:
Haidry N, Ranganatha N, Raj R, Kashyap S, Kumar A, Singh A. Bupivacaine for surgical removal of impacted mandibular third molar: A comparative evaluation with lignocaine. Int J Oral Care Res [serial online] 2019 [cited 2020 Feb 19];7:81-3. Available from: http://www.ijocr.org/text.asp?2019/7/4/81/271306




  Introduction Top


Pain is a universal fear, which a person wants to avoid, and it is the pain associated with a procedure, which makes a person very anxious about the surgical procedure.[1] Local anesthetics are the safest and the most effective drugs available for the prevention and management of pain. Indeed, there is no other drug preventing the propagation of nociceptive nerve impulses from reaching the central nervous system, where it would be interpreted as pain.[2]

Local anesthetics are the mainstay of intraoperative pain control for most dental surgeries, but adequate pain control is still a major treatment concern. Recent advances in agents/techniques have changed dental practice, allowing a safer and pain-free surgical experience.[3] Lignocaine was introduced in 1948 and it is still considered a gold standard local anesthetic agent. Lignocaine is used widely because of its low cost and rapid duration of onset after injection.[1] Lignocaine has a pKa of 7.85 and diffuses readily through the interstitial tissues and into the lipid-rich nerve fibers giving a rapid onset of anesthesia.

Bupivacaine was introduced in 1957. Bupivacaine has an intermediate onset of action and pKa of 8.1, it exists primarily (80%–95%) in the cationic form at the tissue pH of 7.4, and hence is relatively slower in onset compared to lignocaine.[4] Bupivacaine is four times as potent as lignocaine at equivalent doses. On this basis, 0.5% bupivacaine should be equally effective as a 2% lignocaine. As bupivacaine is also approximately four times toxic as lignocaine, their toxicities at these concentrations should be equal at equivalent doses.[5] Surgical extraction of impacted third molars is considered as the standard clinical model in pain studies due to evidence of moderate to severe postoperative pain, which leads to increased pain perception and causes patient dissatisfaction.[6] Some authors suggest the use of bupivacaine as a local anesthetic because of its extended duration of action and less requirement of postoperative analgesia.[1] Not many studies that compare the efficacy of bupivacaine and lignocaine are published. This study was aimed to compare the efficacy of bupivacaine with that of lignocaine, which has already proven its efficacy in surgical removal of the impacted third molar.


  Materials and Methods Top


A single-blind randomized clinical trial was conducted to compare bupivacaine with lignocaine to evaluate the efficacy of bupivacaine. Lignocaine was chosen as the reference substance, as its effects are well-documented in the literature. A total of 25 patients in the age-group of 18–40 years referred to the department of oral surgery for surgical removal of impacted mandibular third molar were randomly selected and were randomly allocated to one of the two groups. In Group-I, lignocaine (2%) with 1:80,000 adrenaline was used as a local anesthetic, and in Group-II, bupivacaine (0.5%) with 1:200,000 adrenaline was used as a local anesthetic. A written informed consent was obtained from all the patients before the procedure. The patients who were allergic to lignocaine or bupivacaine, pregnant, used analgesics within 24h before extraction procedure, used a sedative, had uncontrolled underlying systemic disease such as cardiovascular disease and diabetes mellitus, and were immunosuppressed were excluded from the study.

All the patients were explained about visual analog scale (VAS) pro forma preoperatively. A standard inferior alveolar nerve block technique was used for the local anesthesia. A total of 3mL local anesthetic agent was deposited in each patient in both the groups. A standard operative technique was used for the removal of the impacted mandibular third molar. The patients were asked to report numbness of lip and tongue as well as the time of loss of anesthesia as soon as noticed. The onset of anesthesia, duration of anesthesia, and postoperative pain were recorded. The patients were instructed to record their postoperative pain intensity on a VAS, ranging from 0 = no pain to 10 = worst pain. The data were subjected to statistical analysis, and the P value was calculated for inference.


  Results Top


The results showed the mean time of onset of action for lignocaine and bupivacaine as 2.6 and 5min, respectively. The mean difference between the duration of onset of action was 2.4min, which was statistically significant [Table 1].
Table 1: Onset of action and duration of anesthesia

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The mean duration of anesthesia for bupivacaine was 5.1h with a range of 3–8h. The mean duration of anesthesia for lignocaine was 2.4h. The mean difference between the duration of anesthesia for bupivacaine and lignocaine was 2.7h, which was statistically significant.

The mean pain score recorded after 4h was 4.8 for lignocaine and 2.1 for bupivacaine with a mean difference of 2.7, which was statistically significant. The mean pain score at the eighth postoperative hour showed a value of 3.2 for bupivacaine and 4.3 for lignocaine with a mean difference of 1.1, which was statistically significant [Table 2].
Table 2: Pain intensity on visual analog scale

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  Discussion Top


Local anesthetics block generation and conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in nerve, by slowing the propagation of nerve impulses, and by reducing the rate of rising of the action potential.[7] The conventional local anesthetics are short-acting, and in most oral surgical procedures, a prolonged duration of analgesia is desirable. Third molar surgery with bone guttering can cause a lot of physical and mental agony, so long-acting local anesthetic can be useful due to their longer anesthetic effects and delay in pain onset.[3] Adelusi et al.[4] found lidocaine has a shorter onset of action than bupivacaine. The reason for the shorter duration of onset of action has been attributed to the smaller pKa (7.7) of lidocaine, which allows it to be able to diffuse faster than bupivacaine with larger pKa (8.1), resulting in shorter latency time for lidocaine.[4] In our study, lignocaine showed a shorter onset of action from the time of injection with a mean value of 2.5min compared to that of bupivacaine, which had onset beyond approximately 5min on an average.

Agarwal et al.[3] reported 434min as the mean duration of anesthesia for bupivacaine and 169min for lignocaine, with the mean difference being statistically significant. A vast difference in pain-free duration between the two anesthetics suggests the benefit in using bupivacaine for extended numbness and analgesia postoperatively in the surgical removal of impacted teeth.[3] In this study, the mean duration of anesthesia for bupivacaine and lignocaine was 5.1 and 2.7h, respectively. The mean difference was 2.7h, which was statistically significant.

The perception and intensity of pain are multifactorial, encompassing sensorial and affective factors, thus making it difficult to measure it accurately. Although VAS may show deficiencies regarding understanding and perception, it provides a validated and meaningful measure of efficiency of anesthetic.[8] Pain after third molar surgery can be of varying intensity and has been found to correlate with the duration of the procedure and the amount of surgical trauma. The maximum postoperative pain is usually experienced during the first 6–8h so the use of bupivacaine improves postoperative comfort and reduces the need for strong analgesics.[3] Consistent evidence from literature has shown that short-acting local anesthetics are not clinically effective in the control of the postoperative period when maximum pain intensity is reached. Nespeca[9] observed severe postoperative pain, which abruptly occurred with the cessation of anesthesia using 2% lignocaine with adrenaline even before the effect of the anesthetic had completely worn off. In their study, Chapman and Gordon Macleod[5] found that mean pain score recorded after 4h was significantly lower with bupivacaine than that with lidocaine. Pain scores at 8th h after initial pain onset were not significantly different between the two groups. The onset of postoperative pain has been reported as more gradual with bupivacaine compared to that with lignocaine.[5] In their study, DeJong and Bonin[10] found that the bupivacaine has a greater therapeutic ratio than lignocaine when used for the surgical removal of the impacted third molar. In this study, the mean pain score recorded at 4 and 8h was significantly lower with bupivacaine than that with lignocaine.


  Conclusion Top


Both lignocaine and bupivacaine have their merits and demerits. Many oral surgical operations are technically difficult and prolonged, resulting in considerable postoperative pain and discomfort, especially over the first 8h. Long-lasting local anesthetics can eliminate a considerable amount of this unwanted experience.

This study has been able to show that bupivacaine provides a better and prolonged anesthesia and analgesia postoperatively during the surgical removal of impacted third molars. The use of bupivacaine in minor oral surgical procedures, especially in the removal of impacted mandibular third molar teeth, is desirable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Malik A, Majeed S. Efficacy of bupivacaine 0.5% and lignocaine 2% in minor oral surgical procedures. IOSR J Dent Med Sci 2018;17:28-9.  Back to cited text no. 1
    
2.
Malamed SF. Handbook of Local Anesthesia. 5th ed. St. Louis, MO: Mosby;2004. p. 5.  Back to cited text no. 2
    
3.
Agarwal P, Jain K, Kumar S, Mahajan T, Daga D. Comparative evaluation of bupivacaine and lignocaine for impacted mandibular third molar removal. World J Pharm Res 2017;6:698-705.  Back to cited text no. 3
    
4.
Adelusi E, Abiose O, Gbolahan O. Post intra-alveolar extraction analgesia of bupivacaine and lidocaine: A randomized controlled clinical trial. Dentistry 2019;9:540.  Back to cited text no. 4
    
5.
Chapman P, Gordon Macleod A. A clinical study of bupivacaine for mandibular anesthesia in oral surgery. Anesth Prog 1985;32:69-72.  Back to cited text no. 5
    
6.
Brajkovic D, Biocanin V, Milic M, Vucetic M, Petrovic R, Brkovic B. Quality of analgesia after lower third molar surgery: A randomised, double-blind study of levobupivacaine, bupivacaine and lidocaine with epinephrine. Vojnosanit Pregl 2015;72:50-6.  Back to cited text no. 6
    
7.
Balakrishnan K, Ebenezer V, Dakir A, Kumar S, Prakash D. Bupivacaine versus lignocaine as the choice of local anesthetic agent for impacted third molar surgery, a review. J Pharm Bioall Sci 2015;7:S230-3.  Back to cited text no. 7
    
8.
Shruthi R, Kedarnath S, Mamtha N, Rajaram P, Dinesh B. Articaine for surgical removal of impacted third molar—A comparison with lignocaine. J Int Oral Health 2013;5:48-53.  Back to cited text no. 8
    
9.
Nespeca J. Clinical trials with bupivacaine in oral surgery. Oral Surg Oral Med Oral Pathol 1976;42:301-4.  Back to cited text no. 9
    
10.
DeJong R, Bonin J. Local anesthetics: Injection route alters relative toxicity of bupivacaine. Anesth Analg 1980;59:925-8.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]



 

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