A Retrospective Cross-Sectional Study of the Effect of Liposomal Bupivacaine on Postoperative Opioid Prescribing After Third Molar Extraction.

PURPOSE: Reducing opioid prescriptions after third molar extraction may decrease the risk of opioid dependence. This study compared prescribed morphine milligram equivalents (MMEs) in patients undergoing mandibular third molar removal with and without use of liposomal bupivacaine (LB). METHODS: This retrospective cross-sectional study included deidentified data from electronic medical records of patients who underwent extraction of ≥1 partial bony-or full bony-impacted mandibular third molar at 2 oral surgery centers in the United States in 2012 or 2018. The primary predictor variable was use of LB 133 mg. The primary outcome variable was total prescribed opioids in MMEs. The secondary outcome variable was rate of prescription refills. Both univariate and multivariable regression analyses were used to compare MMEs between groups with a significance level of P < .05. RESULTS: The study sample included 600 subjects (n = 300 each for LB and non-LB groups). Mean age (22-24 years) and sex distribution (55%-58% female) were comparable between groups, although significant differences were observed in anesthesia type and race distribution (P < .05). In univariate analysis, the LB group was prescribed 59% fewer MMEs than the non-LB group (47.1 vs 113.8 MMEs; rate ratio, 0.41 [0.39-0.44]; P < .0001). After adjustment for age, sex, anesthesia type, American Society of Anesthesiologists physical status classification, and complications, the LB group was prescribed significantly fewer total opioids (adjusted MMEs, 44.9 vs 109.5; rate ratio, 0.41 [95% confidence interval, 0.39-0.44]; P < .0001) and had a significantly lower opioid prescription refill rate (3.3% vs 7.7%; odds ratio, 0.38 [95% confidence interval, 0.16-0.90]; P = .028) than the non-LB group. Complication rates were comparable between groups. CONCLUSIONS: Patients undergoing third molar extraction and receiving LB were prescribed significantly fewer opioids than patients who did not receive LB, with a lower refill rate. Use of LB may reduce opioid prescriptions for postsurgical analgesia.

Current Concepts of Periapical Surgery: 2020 Update.

Although conventional endodontic procedures are very successful, failure of the initial treatment can occur. Consideration for surgical treatment versus endodontic retreatment needs to be part of the decision along with thoughts of extraction with implant replacement. Apical surgery can preserve many teeth that remain symptomatic after conventional endodontic treatment especially because endodontic failure can occur after 1 year, usually after a definitive restoration is placed. This article reviews current indications for periapical surgery and discusses factors that can predict successful outcomes.

Preoperative Evaluation and Patient Selection for Office-Based Oral Surgery Anesthesia.

Provision of an outpatient anesthetic requires careful review of the patient's medical history along with salient aspects of the physical examination. The oral and maxillofacial surgeon may need to consult with the patient's medical providers to gain an understanding of the patient's potential risks for an adverse event. This article reviews key aspects of the patient evaluation so that an informed determination of suitability for an office anesthetic can be made.

Providing Anesthesia in the Oral and Maxillofacial Surgery Office: A Look Back, Where We Are Now and a Look Ahead.

Throughout its development the practice of oral and maxillofacial surgery has been richly associated with the provision of anesthetic services. Dentists and particularly oral and maxillofacial surgeons have advanced the science associated with anesthesia especially in the outpatient setting. This article will look back on the development of anesthesia as it relates to oral and maxillofacial surgery, discuss the current mode of anesthesia in the oral surgeon's practice and look ahead to what innovations are advancing this field.

Liposomal Bupivacaine Use in Third Molar Impaction Surgery: INNOVATE Study.

The analgesic efficacy and safety of liposomal bupivacaine (LB) in third molar extraction was evaluated in this phase 3, double-blind, placebo-controlled study of subjects undergoing bilateral third molar extraction. Subjects were randomized 2 : 1 to infiltration with LB (133 mg/10 mL) or placebo, and received opioid rescue medication as needed. Primary efficacy measure was cumulative area under the curve (AUC) of numeric rating scale (NRS) pain severity scores through 48 hours (AUC of NRS0-48) postsurgery. Other measures included AUC of NRS0-24, AUC of NRS0-72, and AUC of NRS0-96, and incidence of adverse events. There were 150 subjects in the primary efficacy population (n = 99 LB, n = 51 placebo) and 89 in the per-protocol population (n = 59 LB, n = 30 placebo). Least-squares mean for AUC of NRS0-48 was 172.3 LB versus 194.7 placebo (P = .227) in the primary efficacy population and 120.8 LB versus 183.3 placebo (P = .023) in the per-protocol population. At all time points, between-group differences in AUC of NRS scores were significant in the per-protocol population (LB lower than placebo, P < .05) but not in the primary efficacy population. The adverse event profile was similar between groups. LB produced significantly lower cumulative pain scores versus placebo at all time points in the per-protocol analysis but not in the primary efficacy analysis because of protocol violations. This study indicates significant improvement in pain scores in the third molar model, but because of extensive protocol violations additional studies are warranted to demonstrate effectiveness.

Current Concepts of Periapical Surgery.

Preoperative decision-making is vital to determine potential success of periapical surgery. Adequate exposure of the root apical region is best approached via a sulcular-type incision. Surgical procedures include resection of 2 to 3 mm of the apical portion along with root end preparation and seal. The surgeon must decide if submission of periapical tissues to pathology is indicated.

Unusual case of a sialolith: a case report.

Sialoliths are a common cause of salivary gland obstruction, usually affecting the submandibular gland. Although many theories are postulated for their formation (dehydration, medications that reduce salivary flow, increased salivary viscosity), no one aspect is clearly the primary etiology. This case report details an unusual case in which a facial hair of the patient apparently became entrapped in Wharton's duct, causing a nidus for the formation of a sialolith.

Sedation in the oral and maxillofacial surgery office.

The control of pain in dentistry is an expectation that patients have. With the administration of appropriate local anesthetics, most procedures can be accomplished without eliciting pain. However, the anxiety leading up to the procedure itself and the local anesthetic injection cause many patients to delay and avoid timely care, often leading to the need for more complex and emergent treatment. Even with a complete blockade of the pain from a surgical extraction of a tooth, the pressure and noises associated with the procedure makes it intolerable for many patients to consider the surgery without being "asleep."