|Year : 2018 | Volume
| Issue : 3 | Page : 243-248
Comparative evaluation of hemodynamic, vasoconstrictive, and SpO2variability during different stages of periodontal surgery performed using 0.5% ropivacaine or 2% lignocaine HCl (1:80,000 adrenaline) local anesthesia: A randomized, double-blind, split-mouth pilot study
Ashank Mishra1, Zohra Lalani1, Butchibabu Kalakonda2, Preeti Krishnan1, Ruchi Pandey3, Krishnajaneya Reddy1
1 Department of Periodontics, Sri Sai College of Dental Surgery, Hyderabad, Telangana, India
2 Department of Preventive Dental Sciences, Al-Farabi Dental College, Riyadh, Saudi Arabia
3 Department of Periodontics, Manav Rachna Dental College, Faridabad, Haryana, India
|Date of Submission||07-Jan-2018|
|Date of Acceptance||10-Apr-2018|
|Date of Web Publication||8-Jun-2018|
Dr. Ashank Mishra
Department of Periodontics, Sri Sai College of Dental Surgery, Kothrepally, Vikarabad, Hyderabad - 501 101, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study is to compare anesthetic, hemodynamic, vasoconstrictive, and SpO2variability of 0.5% ropivacaine to the “gold standard” lignocaine (2%) with epinephrine (1:80,000) during periodontal surgery. Materials and Methods: A total of 20 systemically healthy controls meeting the inclusion criteria were selected from the Outpatient Department of Sri Sai College of Dental Surgery. Preoperatively, all participants were infiltrated with 0.5 ml of 0.5% ropivacaine intradermally as test solution to record any allergic reaction. Open flap debridement was performed using local anesthesia containing 2% lignocaine hydrochloride with 1:80,000 epinephrine or 0.5% ropivacaine. Recordings were made of the time of onset, duration of action, the intensity, and depth of anesthesia and various hemodynamic changes throughout the surgical procedure. In addition, blood loss volume and postoperative pain were also assessed. Results: Ropivacaine showed statistically longer duration of action (mean±SD =5.3±0.71 hrs) than lignocaine with epinephrine (mean=2.14±0.98 hrs). Blood loss during flap surgery was comparatively less when performed under ropivacaine. No statistical differences were observed in systolic BP, diastolic BP, SpO2 and heart rate during different stages of periodontal surgery between either of the local anesthetic agents Conclusion: Ropivacaine demonstrates comparable efficacy as lignocaine with added advantage of longer duration of action and superior postoperative pain control. No adverse events from this newer anesthetic were noted, and hence, it can be used safely as a viable local anesthetic for periodontal surgical procedures.
Keywords: Anesthesia, lignocaine, periodontal surgery, ropivacaine
|How to cite this article:|
Mishra A, Lalani Z, Kalakonda B, Krishnan P, Pandey R, Reddy K. Comparative evaluation of hemodynamic, vasoconstrictive, and SpO2variability during different stages of periodontal surgery performed using 0.5% ropivacaine or 2% lignocaine HCl (1:80,000 adrenaline) local anesthesia: A randomized, double-blind, split-mouth pilot study. J Indian Soc Periodontol 2018;22:243-8
|How to cite this URL:|
Mishra A, Lalani Z, Kalakonda B, Krishnan P, Pandey R, Reddy K. Comparative evaluation of hemodynamic, vasoconstrictive, and SpO2variability during different stages of periodontal surgery performed using 0.5% ropivacaine or 2% lignocaine HCl (1:80,000 adrenaline) local anesthesia: A randomized, double-blind, split-mouth pilot study. J Indian Soc Periodontol [serial online] 2018 [cited 2020 Jul 9];22:243-8. Available from: http://www.jisponline.com/text.asp?2018/22/3/243/233989
| Introduction|| |
The use of local anesthetic has become an important aspect in pain management during periodontal surgery. An ideal local anesthetic agent for routine periodontal surgery should have a rapid onset of action, no untoward side effects, a large therapeutic index, and a predictable duration of action.
The most commonly used local anesthetic agent in periodontal practice is lignocaine which is considered as “gold standard” for dental surgical procedures. Lignocaine along with epinephrine has a limited duration of action (2–3 h). Addition of epinephrine to this anesthetic provides vasoconstrictive benefits but carries a disadvantage of having systemic side effects, especially on the cardiovascular system.
Thus, there is a need for an alternative anesthetic that overcomes the limitations of lignocaine. Ropivacaine offers a possible substitute, being a longer acting amide-type anesthetic having substantially lower cardio and neurotoxic effects compared with other long-term local anesthetics. It was first introduced in 1996. Ropivacaine (naropin) is similar in structure to both mepivacaine and bupivacaine but, unlike these two drugs, is a monohydrate of the hydrochloride salt of 1-propyl-2',6' pipecoloxylidide prepared as an S-enantiomer. The rationale for replacing racemic bupivacaine with the S-enantiomer, ropivacaine, was to provide a wider margin of safety with the same analgesic efficacy and less postoperative motor block.
Ropivacaine also possesses an inherent vasoconstrictive action in contrast to lignocaine. Some studies have shown that the addition of a vasoconstrictor to ropivacaine does not improve its efficacy or duration compared with the drug alone., Thus, this property of inherent vasoconstriction precludes the addition of vasoconstrictor and hence prevents the associated systemic side effects.
Ropivacaine has been used for subcutaneous infiltration; epidural, intrathecal, and peripheral nerve block surgery; and postoperative analgesia. However, limited evidence of its use in periodontal surgery is available.
Hence, the present study was put forward to compare the efficacy of 0.5% ropivacaine to 2% lignocaine HCl with epinephrine (1:80,000) during periodontal surgery.
| Materials and Methods|| |
This study was conducted in dental college in India from September 1, 2016, to December 25, 2016, and the study protocol was approved by the Institutional Ethical Committee (IRB number: 440/sscds/IRB-E/OS/2014).
The study population comprised 20 systemically healthy subjects (10 males and 10 females), aged between 30 and 50 years diagnosed with generalized moderate-to-severe chronic periodontitis as per the 1999 American Academy of Periodontology classification.
Potential patients were selected from those referred to the postgraduate clinic of the Department of Periodontics.
The criteria for patients to be included in the study were as follows
- The presence of at least two sites with PPD ≥5 mm in the teeth 15–17 and 25–27 when measured with a manual periodontal probe (UNC-15, Hu-Friedy, Chicago, Illinois, USA) along with bone loss observed on intraoral periapical radiograph
- No history of systemic diseases
- No history of antibiotics for the last 6 months
- No history of periodontal treatment and
- No history of allergy to sulfites, amide-type local anesthetics, or any ingredients in the anesthetic solution.
The patients were excluded if they had any of the following reasons
- Pregnant and lactating females
- Those with cardiac diseases such as hypertension, myocardial infarction etc.
The study procedure was verbally explained to all the participants and a written informed consent was obtained before the initiation of the study. All the patients were instructed on oral hygiene and Phase I periodontal treatment was carried out comprising thorough scaling and root planing with ultrasonic scalers and hand instruments for all the patients. Four to 6 weeks after initial phase of the treatment, a reassessment was made to evaluate the periodontal disease status by recording the clinical parameters which included PPD (probing pocket depth), CAL (Clinical attachment level), BOP (bleeding on probing), and mobility. For all the participants, an O'Leary plaque score <20, modified gingival index  ≤2, and presence of persistent pockets related to atleast two sites with PPD ≥5 mm in the teeth 15–17 and 25–27 was prerequisite before undertaking surgical phase of the therapy. All patients were infiltrated with 0.5 ml of 0.5% ropivacaine intradermally as test solution to record any allergic reaction.
The randomized clinical study had a double-blinded, split-mouth design. The choice of anesthetic to be administered was achieved through a simple randomization method (by toss of a coin) and either of the anesthetics were assigned to the right or the left halves of the same patient's maxillary dentition. The contralateral side surgery was done post 2 weeks ensuring split-mouth design.
All patients received local anesthesia containing 2% lignocaine hydrochloride with 1:80,000 epinephrine (Lignox 2% A, Indoco Remedies Ltd., India), or 0.5% ropivacaine (Ropin 0.5%, Neon Laboratories Ltd., India) [Figure 1] using the infiltration technique into the vestibular depth on the buccal side (2 ml) and greater palatine nerve block on the palatal side (0.5 ml) using a single sterile luer-lock disposable syringe. A single-trained examiner (AM) administered local anesthetic to all the patients.
All patients were operated by the same surgeon (ZL) who was blinded about the anesthetic being used. Open flap debridement was performed by giving intracrevicular incisions and raising full-thickness mucoperiosteal flaps buccally and palatally [Figure 2]. The granulation tissue was removed, and the roots were thoroughly scaled and planed. The mucoperiosteal flaps were repositioned and sutured with interrupted sutures (4-0 Mersilk, Ethicon, UK) and a noneugenol periodontal dressing (Coe Pack, GC American Inc., IL, USA) was placed to protect the surgical area.
- Onset of anesthesia: Recordings were made of the time of onset of anesthesia based on both the subjective and objective assessment. Subjective assessment was confirmed by the description of symptoms of anesthesia such as numbness of buccal mucosa by the patient. Objective assessment of the onset of anesthesia was confirmed by applying pressure against the attached gingiva of the anesthetized teeth with a sharp-edged instrument
- The intensity of pain and depth of anesthesia: This was assessed subjectively using a visual analog scale (VAS) that ranged from 0 to 10 (0 = No pain, 10 = Worst pain experienced ever). Patients were asked to respond to the VAS score as soon as they started feeling numbness in the buccal mucosa and immediately after the numbness was lost postoperatively. The patients were asked to score the “amount of pain” felt during the periodontal surgery
- Hemodynamic changes: Heart rate, blood pressure, and peripheral capillary oxygen saturation (SpO2) were examined during five steps; the first step before injecting the anesthetic, the second step after the anesthetic injection and before the incision, the third step after the incision, the fourth step after debridement, and the fifth step following suturing.
Heart rate and SpO2 levels were measured by finger pulse oximeter (Shree Balaji Surgical Pvt. Ltd., Mumbai, India) [Figure 3] attached to the patient's finger during periodontal surgery. Blood pressure was measured by manual sphygmomanometer (Bharat Enterprises, Hyderabad, India).
Volume of blood loss
During flap surgery, a high vacuum suction was used which was connected to a portable calibrated jar [Figure 4]. The patient was instructed not to spit during the surgery. The actual volume of blood loss was assessed by the following formula (cyanmethemoglobin method).
Volume of blood lost = (Hb) recovered × volume of aspirated blood/(Hb) whole blood.
All the participants were given analgesics (400 mg ibuprofen + 325 mg paracetamol) three times daily for 3 days postoperatively. Patients were asked to call back once they start feeling pain or discomfort or lost numbness in the area of operation before taking analgesics. A chart was given to the patients to record the time and date of analgesic intake which was revaluated at 1 week. This was cross-checked with the number of tablets remaining. The patients were also enquired about any adverse events such as itching, redness, or any swelling elicited after the immediate administration of the anesthetic and through a telephone follow-up after 24 h and by examination at the time of suture removal. One week after the surgery, periodontal dressing was removed followed by suture removal. After 2 weeks, contralateral surgery was performed using another anesthetic. Data were analyzed by using the statistical software, Statistical Package for the Social Sciences version 20.0 for Windows (SPSS Inc., Chicago, IL, USA). Since the data demonstrated nonnormal distribution, nonparametric test, namely, Mann–Whitney test was used to assess intergroup variations, and P < 0.05 was considered as statistically significant.
| Results|| |
The present study included 20 systemically healthy controls diagnosed with chronic generalized moderate-to-severe periodontitis with age of 30–50 years (mean ± standard deviation [SD]: 38.8 ± 2.04 years) (10 males and 10 females).
None of the included patients showed any allergy to either of the agents. Ropivacaine showed statistically significant longer duration of action (mean ± SD = 5.3 ± 0.71 h) than lignocaine with epinephrine (mean = 2.14 ± 0.98 h). In addition, a statistically significant difference was found with respect to the onset of action, with ropivacaine taking longer (mean ± SD = 5.03 ± 1.84 min) when compared to lignocaine (mean = 2.54 ± 0.39 min). In addition, blood loss was comparatively less when flap surgery was performed under ropivacaine (mean ± SD (ropivacaine) = 21.66 ± 6.63 ml, mean ± SD (lignocaine + epinephrine) = 38.8 ± 2.04 ml) [Table 1].
There was a transient increase in the systolic blood pressure and SpO2 immediately after the anesthetic was given and this came down gradually. No statistical differences were observed in systolic BP, diastolic BP, SpO2, and heart rate during different stages of periodontal surgery between either of the local anesthetic agents [Table 2] and [Figure 5]. No significant differences were observed with respect to VAS scores between the two agents. Patients tended to consume greater number of analgesics when surgery was performed under lignocaine + 1:80,000 epinephrine (average % of analgesic consumption by patients: 50%) than with ropivacaine (34%).
|Table 2: Intergroup comparison for blood pressure, peripheral capillary oxygen saturation and heart rate using Mann-Whitney test|
Click here to view
|Figure 5: Changes in mean systolic, diastolic blood pressure, SpO2, and heart rate during different stages of periodontal flap surgery|
Click here to view
| Discussion|| |
Lignocaine has been the undisputed “gold standard” local anesthetic agent in periodontal surgical procedures for decades. However, in recent times, alternative anesthetic agents such as ropivacaine have gained prominence for various dental procedures owing to its inherent beneifts. Ropivacaine causes reversible inhibition of sodium ion influx and thereby blocks conduction of impulses by nerve fibers.
The present double-blind, split-mouth clinical study was designed with the aim to assess the efficacy of 0.5% ropivacaine when compared to 2% lignocaine HCl with epinephrine (1:80 000) during periodontal surgery. The results of the present study indicate that ropivacaine, at 0.5% concentration exhibits comparable efficacy as lignocaine in the treatment of patients with generalized chronic periodontitis through periodontal surgery.
The present study has compared the onset time of action of anesthesia between lignocaine and ropivacaine and found that there were significant differences. The results denote that there was a rapid onset of action with lignocaine (mean = 2.54 ± 0.39 min) in comparison to ropivacaine (mean = 5.03 ± 1.84 min) (pKa value of ropivacaine = 8.07). The quicker onset of sensory block with lignocaine may be attributed to its pKa value (7.86) which is close to physiological pH (7.4). Due to this property, the ionized fraction of lignocaine increases, leading to a quicker penetration into nerves and quicker onset as compared to ropivacaine. Keramidas et al. also reported rapid onset of anesthesia with lignocaine than ropivacaine in digital nerve block anesthesia. In contrast to the present study, Krzemiński et al. reported shorter onset of action with ropivacaine than lignocaine for pulpal anesthesia.
Regarding duration of action, ropivacaine showed statistically significant difference (mean = 5.26 h) than lignocaine with epinephrine (mean = 2.06 h). Ropivacaine has a weaker bond to the extraneural fat and tissues, hence, has a greater availability for transfer to the nerve site as reported by Akerman et al. The prolonged duration of anesthesia with ropivacaine might also be attributed to its inherent vasoconstrictive properties together with its strong ability to bind to plasma proteins.
It has been reported that the addition of epinephrine to ropivacaine has been shown not to improve the anesthetic effect. The present study compared this inherent vasoconstrictive action of ropivacaine to that of 1:80,000 epinephrine in lignocaine solution regarding volume of loss of blood. Statistically significant differences were observed between the two agents, with ropivacaine showing less blood loss than epinephrine. McIvor and Wengraf reported that the maximal volume of blood loss during periodontal surgery was 62 ml and the minimal was 0.5 ml. Moore et al. described that the intraoperative hemorrhage ranged from 54.9 ± 36.0-70.2 ± 53.0 ml (depending on epinephrine concentration in the local anesthetic). In the present study, blood loss volume with lignocaine + 1:80,000 epinephrine ranged from 35 to 42 ml (mean ± SD = 38.8 ± 2.04 ml) and that of ropivacaine ranged from 10 to 30 ml (21.66 ± 6.63 ml). However, many other reasons could be accounted for decreased blood loss during flap surgery performed under ropivacaine. They include, the duration of surgery, the presence of inflammation, the severity of periodontal destruction, etc., Hence, within the limitations of the present study, it could not be concluded that the vasoconstrictive action of ropivacaine is superior to 1: 80,000 epinephrine. Further studies with a larger sample size are required to assess this parameter more efficiently.
Furthermore, the results of the present study show that the patients who underwent periodontal surgery under ropivacaine had a less postoperative need for analgesic consumption compared to the patients who underwent surgery under lignocaine. This postoperative analgesic property of ropivacaine might be attributed to its selective action on the pain-transmitting Aδ and C nerve fibers rather than Aβ fibers, which are involved in motor function. This analgesic property of ropivacaine has also been reported by many other studies., No differences were reported between the two agents with respect to hemodynamic changes. In addition, no adverse events were reported with either of the agents during or after surgery. To the best of the author's knowledge, there were no studies that have used ropivacaine as an anesthetic agent in periodontal surgery. Our study was the first-of-its-kind to have used ropivacaine as a local anesthetic agent in periodontal surgery. Hence, a comparative evaluation of the outcomes reported in our study could not be corroborated with any other studies.
This clinical study confirms that, ropivacaine, at 0.5% concentration demonstrates comparable efficacy as lignocaine with added advantage of longer duration of action, superior postoperative pain control, and decreased blood loss. However, this study measured only hemodynamic changes; hence, further studies with a larger sample size are required to assess detailed effects of ropivacaine on cardiovascular system. To conclude, ropivacaine can be considered as a viable substitute agent for local anesthesia in periodontal surgery.
| Conclusion|| |
This clinical study confirms that, ropivacaine, at 0.5% concentration demonstrates comparable efficacy as lignocaine with added advantage of longer duration of action, superior post-operative pain control and decreased blood loss. However, this study measured only hemodynamic changes, hence, further studies with a larger sample size are required to assess detailed effects of ropivacaine on cardiovascular system. To conclude, ropivacaine can be considered as a viable substitute agent for local anesthesia in periodontal surgery.
We would like to acknowledge Dr. A Jayakumar for his support throughout the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McClure JH. Ropivacaine. Br J Anaesth 1996;76:300-7.
Lee A, Fagan D, Lamont M, Tucker GT, Halldin M, Scott DB, et al.
Disposition kinetics of ropivacaine in humans. Anesth Analg 1989;69:736-8.
Löfström JB. 1991 labat lecture. The effect of local anesthetics on the peripheral vasculature. Reg Anesth 1992;17:1-1.
Cederholm I, Anskär S, Bengtsson M. Sensory, motor, and sympathetic block during epidural analgesia with 0.5% and 0.75% ropivacaine with and without epinephrine. Reg Anesth 1994;19:18-33.
Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z. Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block. Anesth Analg 2001;93:1327-31.
Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.
O'Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38.
Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker L. A modified gingival index for use in clinical trials. Clin Prev Dent 1986;8:3-6.
Pilcher F, Sheard C. Measurements on the loss of blood during transurethral prostate resection and other surgical procedures, determined by spectrophotometric and photelometric methods. Proc Staff Meet Mayo Clin 1937;12:209.
Kuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology and clinical use. Indian J Anaesth 2011;55:104-10.
] [Full text]
Becker DE, Reed KL. Local anesthetics: Review of pharmacological considerations. Anesth Prog 2012;59:90-101.
Keramidas EG, Rodopoulou SG. Ropivacaine versus lidocaine in digital nerve blocks: A prospective study. Plast Reconstr Surg 2007;119:2148-52.
Krzemiński TF, Gilowski Ł, Wiench R, Płocica I, Kondzielnik P, Sielańczyk A, et al.
Comparison of ropivacaine and lidocaine with epinephrine for infiltration anesthesia in dentistry. A randomized study. Am J Dent 2011;24:305-9.
Akerman B, Hellberg IB, Trossvik C. Primary evaluation of the local anaesthetic properties of the amino amide agent ropivacaine (LEA 103). Acta Anaesthesiol Scand 1988;32:571-8.
McIvor J, Wengraf A. Blood-loss in periodontal surgery. Dent Pract Dent Rec 1966;16:448-51.
Moore PA, Doll B, Delie RA, Hersh EV, Korostoff J, Johnson S, et al.
Hemostatic and anesthetic efficacy of 4% articaine HCl with 1:200,000 epinephrine and 4% articaine HCl with 1:100,000 epinephrine when administered intraorally for periodontal surgery. J Periodontol 2007;78:247-53.
Wildsmith JA, Brown DT, Paul D, Johnson S. Structure-activity relationships in differential nerve block at high and low frequency stimulation. Br J Anaesth 1989;63:444-52.
Meechan JG. A comparison of ropivacaine and lidocaine with epinephrine for intraligamentary anesthesia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:469-73.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]