Pre-emptive low-dose ketamine with local anesthesia reduces postoperative morbidity after third molar surgery: A systematic review and meta-analysis.
Abstract
Objective: This review addresses a clinical research question related to lower third molar surgery (L3MS): does the combination of pre-emptive low-dose ketamine with local anesthesia (KLA) reduce postoperative complications compared with local anesthesia (LA) alone? Material and methods: A systematic literature search was performed to identify eligible articles by electronic searches of PubMed, Cochrane Central Register of Controlled Trials, EBSCO Library, Web of Science and grey literature through June 2019 without data or language restrictions. We analyzed all randomized controlled clinical studies (RCTs) comparing use of KLA with use of LA in L3MS regarding pain, swelling, and trismus outcomes. The quality of evidence was rated according to Cochrane’s tool for assessing risk of bias. Results: Five RCTs encompassing 230 extraction sites (KLA = 115, LA = 115) were included in this study. The standardized mean difference (SMD) with the 95% confidence interval (CI) was used to synthesize the results. The data show that there were significant differences between the two groups in post-operative pain (SMD -1.464, 95% CI -1.683 to -0.949, p= 0.001) and swelling (SMD -0.450, 95% CI -0.758 to -0.142, p= 0.004, all low quality evidence). However, there was no significant difference in the trismus (SMD -0.754, CI -1.487 to -0.022, p = 0.043, very low quality evidence). Conclusion: The combination of pre-emptive low-dose ketamine with LA significantly decreased pain and swelling within the first 24 hours after L3MS compared with the control group.
References
1. de Boer MP, Raghoebar GM, Stegenga B, Schoen PJ, Boering G. Complications after mandibular third molar extraction. Quintessence Int. 1995;26(11):779-84.
2. Ruta DA, Bissias E, Ogston S, Ogden GR. Assessing health outcomes after extraction of third molars: the postoperative symptom severity (PoSSe) scale. Br J Oral Maxillofac Surg. 2000;38(5):480-7.
3. Larsen PE. The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg. 1991;49(9):932-7.
4. Poeschl PW, Eckel D, Poeschl E. Postoperative prophylactic antibiotic treatment in third molar surgery--a necessity? J Oral Maxillofac Surg. 2004;62(1):3-8; discussion 9.
5. Fernando S, Hill CM, Walker R. A randomised double blind comparative study of low level laser therapy following surgical extraction of lower third molar teeth. Br J Oral Maxillofac Surg. 1993;31(3):170-2.
6. Barden J, Edwards JE, McQuay HJ, Wiffen PJ, Moore RA. Relative efficacy of oral analgesics after third molar extraction. Br Dent J. 2004; 197(7):407-11; discussion 397.
7. Fenton DA, Piecuch JF. Perioperative strategies for third molar surgery. Atlas Oral Maxillofac Surg Clin North Am. 2012;20(2):225-32.
8. Gersema L, Baker K. Use of corticosteroids in oral surgery. J Oral Maxillofac Surg. 1992; 50(3):270-7.
9. de Santana Santos T, Calazans AC, Martins-Filho PR, Silva LC, de Oliveira E Silva ED, Gomes AC. Evaluation of the muscle relaxant cyclobenzaprine after third-molar extraction. J Am Dent Assoc. 2011;142(10):1154-62.
10. Satilmiş T, Garip H, Arpaci E, Sener C, Göker K. Assessment of combined local anesthesia and ketamine for pain, swelling, and trismus after surgical extraction of third molars. J Oral Maxillofac Surg. 2009;67(6):1206-10.
11. Launo C, Bassi C, Spagnolo L, Badano S, Ricci C, Lizzi A, Molinino M. Preemptive ketamine during general anesthesia for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. Minerva Anestesiol. 2004;70(10):727-34.
12. Ong EL, Osborne GA. Ketamine for co-induction of ana-esthesia in oral surgery. Ambulatory surgery. 2001; 9(3):131-5.
13. Lebrun T, Van Elstraete AC, Sandefo I, Polin B, Pierre-Louis L. Lack of a pre-emptive effect of low-dose ketamine on postoperative pain following oral surgery. Can J Anaesth. 2006;53(2):146-52.
14. Garip H, Satılmış T, Dergin G, Uğurlu F, Göker K. Effects of midazolam/low-dose ketamine conscious intravenous sedation on pain, swelling, and trismus after surgical extraction of third molars. J Oral Maxillofac Surg. 2011;69(4):1023-30.
15. Gupta R, Sharma K, Dhiman UK. Effect of a combination of oral midazolam and low-dose ketamine on anxiety, pain, swelling, and comfort during and after surgical extractions of mandibular third molars. Indian J Dent Res. 2012;23(2):295-6.
16. Hesham T AI, Abd Elghany H. Influence of combined local anesthesia and low dose ketamine injection on postoperative complications following lower third molar surgery oral surgery department. Cairo University, 2014.
17. Kumar A, Kale TP. A Comparative Study between the Effect of Combined Local Anesthetic and Low-dose Ketamine with Local Anesthetic on Postoperative Complications after Impacted Third Molar Surgery. J Contemp Dent Pract. 2015;16(12):957-62.
18. Hadhimane A, Shankariah M, Neswi KV. Pre-Emptive Analgesia with Ketamine for Relief of Postoperative Pain After Surgical Removal of Impacted Mandibular Third Molars. J Maxillofac Oral Surg. 2016;15(2):156-63.
19. Shah A, Halli R, Merchant Y, Kshirsagar R, Khurana J. Efficacy of Ketamine as an Adjunct to Local Anesthesia in the Surgical Removal of Impacted Mandibular Third Molars - A Split Mouth Prospective Controlled Clinical Study. J Clin Diagn Res. 2016;10(10):ZC29-ZC33.
20. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100.
21. Craane B, Dijkstra PU, Stappaerts K, De Laat A. One-year evaluation of the effect of physical therapy for masticatory muscle pain: a randomized controlled trial. Eur J Pain. 2012;16(5):737-47.
22. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). Cochrane, 2020. Available from www.training.cochrane.org/handbook.
23. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-6.
24. GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University, 2015 (developed by Evidence Prime, Inc.). Available from: www.gradepro.org.
25. Schünemann H, Brożek J, Guyatt G, Oxman A. GDT: G: GRADEpro Guideline Development Tool [Software]. (ed., McMaster University, 2015 (developed by Evidence Prime, Inc.), 2015,
26. Üstün Y, Erdoǧan Ö, Esen E, Karsli ED. Comparison of the effects of 2 doses of methylprednisolone on pain, swelling, and trismus after third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96(5):535-9.
27. Erhan OL, Göksu H, Alpay C, Beştaş A. Ketamine in post-tonsillectomy pain. Int J Pediatr Otorhinolaryngol. 2007;71(5):735-9.
28. Yuasa H, Sugiura M. Clinical postoperative findings after removal of impacted mandibular third molars: prediction of postoperative facial swelling and pain based on preoperative variables. Br J Oral Maxillofac Surg. 2004;42(3):209-14.
29. Buyukkurt MC, Gungormus M, Kaya O. The effect of a single dose prednisolone with and without diclofenac on pain, trismus, and swelling after removal of mandibular third molars. J Oral Maxillofac Surg. 2006;64(12):1761-6.
30. Adam F, Libier M, Oszustowicz T, Lefebvre D, Beal J, Meynadier J. Preoperative small-dose ketamine has no preemptive analgesic effect in patients undergoing total mastectomy. Anesth Analg. 1999;89(2):444-7.
31. Reeves M, Lindholm DE, Myles PS, Fletcher H, Hunt JO. Adding ketamine to morphine for patient-controlled analgesia after major abdominal surgery: a double-blinded, randomized controlled trial. Anesth Analg. 2001;93(1):116-20.
32. Dahl V, Ernoe PE, Steen T, Raeder JC, White PF. Does ketamine have preemptive effects in women undergoing abdominal hysterectomy procedures? Anesth Analg. 2000; 90(6):1419-22.
33. Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty. Anesth Analg. 2005;100(2):475-80.
34. Chia YY, Liu K, Liu YC, Chang HC, Wong CS. Adding ketamine in a multimodal patient-controlled epidural regimen reduces postoperative pain and analgesic consumption. Anesth Analg. 1998;86(6):1245-9.
35. Fu ES, Miguel R, Scharf JE. Preemptive ketamine decreases postoperative narcotic requirements in patients undergoing abdominal surgery. Anesth Analg. 1997;84(5):1086-90.
36. Menigaux C, Fletcher D, Dupont X, Guignard B, Guirimand F, Chauvin M. The benefits of intraoperative small-dose ketamine on postoperative pain after anterior cruciate ligament repair. Anesth Analg. 2000;90(1):129-35.
37. Pedersen JL, Galle TS, Kehlet H. Peripheral analgesic effects of ketamine in acute inflammatory pain. Anesthesiology. 1998;89(1):58-66.
38. Safavi M, Honarmand A, Nematollahy Z. Pre-incisional analgesia with intravenous or subcutaneous infiltration of ketamine reduces postoperative pain in patients after open cholecystectomy: a randomized, double-blind, placebo-controlled study. Pain Med. 2011;12(9):1418-26.
39. Honarmand A, Safavi M, Karaky H. Preincisional administration of intravenous or subcutaneous infiltration of low-dose ketamine suppresses postoperative pain after appendectomy. J Pain Res. 2012;5:1-6.
40. Siddiqui AS, Raees US, Siddiqui SZ, Raza SA. Efficacy of pre-incisional peritonsillar infiltration of ketamine for post-tonsillectomy analgesia in children. J Coll Physicians Surg Pak. 2013;23(8):533-7.
41. Tverskoy M, Oren M, Vaskovich M, Dashkovsky I, Kissin I. Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanism: a study in postoperative patients. Neurosci Lett. 1996;215(1):5-8.
42. Lange M, Bröking K, van Aken H, Hucklenbruch C, Bone HG, Westphal M. Einsatz von Ketamin bei Sepsis und systemischen Entzündungsreaktionen [Role of ketamine in sepsis and systemic inflammatory response syndrome]. Anaesthesist. 2006;55(8):883-91.
43. Beilin B, Rusabrov Y, Shapira Y, Roytblat L, Greemberg L, Yardeni IZ, Bessler H. Low-dose ketamine affects immune responses in humans during the early postoperative period. Br J Anaesth. 2007;99(4):522-7.
44. Mazar J, Rogachev B, Shaked G, Ziv NY, Czeiger D, Chaimovitz C, Zlotnik M, Mukmenev I, Byk G, Douvdevani A. Involvement of adenosine in the antiinflammatory action of ketamine. Anesthesiology. 2005;102(6):1174-81.
45. Cho JE, Shim JK, Choi YS, Kim DH, Hong SW, Kwak YL. Effect of low-dose ketamine on inflammatory response in off-pump coronary artery bypass graft surgery. Br J Anaesth. 2009;102(1):23-8.
46. SH Akhlagh, D Zeighami , M.B. Khosravi, B Maghsoodi, S Azemati, A Alipour. The effect of low-dose of ketamine infusion on stress responses in coronary artery bypass graft surgery. Iranian Cardiovasc Res J. 2010; 4(1): e67655
2. Ruta DA, Bissias E, Ogston S, Ogden GR. Assessing health outcomes after extraction of third molars: the postoperative symptom severity (PoSSe) scale. Br J Oral Maxillofac Surg. 2000;38(5):480-7.
3. Larsen PE. The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg. 1991;49(9):932-7.
4. Poeschl PW, Eckel D, Poeschl E. Postoperative prophylactic antibiotic treatment in third molar surgery--a necessity? J Oral Maxillofac Surg. 2004;62(1):3-8; discussion 9.
5. Fernando S, Hill CM, Walker R. A randomised double blind comparative study of low level laser therapy following surgical extraction of lower third molar teeth. Br J Oral Maxillofac Surg. 1993;31(3):170-2.
6. Barden J, Edwards JE, McQuay HJ, Wiffen PJ, Moore RA. Relative efficacy of oral analgesics after third molar extraction. Br Dent J. 2004; 197(7):407-11; discussion 397.
7. Fenton DA, Piecuch JF. Perioperative strategies for third molar surgery. Atlas Oral Maxillofac Surg Clin North Am. 2012;20(2):225-32.
8. Gersema L, Baker K. Use of corticosteroids in oral surgery. J Oral Maxillofac Surg. 1992; 50(3):270-7.
9. de Santana Santos T, Calazans AC, Martins-Filho PR, Silva LC, de Oliveira E Silva ED, Gomes AC. Evaluation of the muscle relaxant cyclobenzaprine after third-molar extraction. J Am Dent Assoc. 2011;142(10):1154-62.
10. Satilmiş T, Garip H, Arpaci E, Sener C, Göker K. Assessment of combined local anesthesia and ketamine for pain, swelling, and trismus after surgical extraction of third molars. J Oral Maxillofac Surg. 2009;67(6):1206-10.
11. Launo C, Bassi C, Spagnolo L, Badano S, Ricci C, Lizzi A, Molinino M. Preemptive ketamine during general anesthesia for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. Minerva Anestesiol. 2004;70(10):727-34.
12. Ong EL, Osborne GA. Ketamine for co-induction of ana-esthesia in oral surgery. Ambulatory surgery. 2001; 9(3):131-5.
13. Lebrun T, Van Elstraete AC, Sandefo I, Polin B, Pierre-Louis L. Lack of a pre-emptive effect of low-dose ketamine on postoperative pain following oral surgery. Can J Anaesth. 2006;53(2):146-52.
14. Garip H, Satılmış T, Dergin G, Uğurlu F, Göker K. Effects of midazolam/low-dose ketamine conscious intravenous sedation on pain, swelling, and trismus after surgical extraction of third molars. J Oral Maxillofac Surg. 2011;69(4):1023-30.
15. Gupta R, Sharma K, Dhiman UK. Effect of a combination of oral midazolam and low-dose ketamine on anxiety, pain, swelling, and comfort during and after surgical extractions of mandibular third molars. Indian J Dent Res. 2012;23(2):295-6.
16. Hesham T AI, Abd Elghany H. Influence of combined local anesthesia and low dose ketamine injection on postoperative complications following lower third molar surgery oral surgery department. Cairo University, 2014.
17. Kumar A, Kale TP. A Comparative Study between the Effect of Combined Local Anesthetic and Low-dose Ketamine with Local Anesthetic on Postoperative Complications after Impacted Third Molar Surgery. J Contemp Dent Pract. 2015;16(12):957-62.
18. Hadhimane A, Shankariah M, Neswi KV. Pre-Emptive Analgesia with Ketamine for Relief of Postoperative Pain After Surgical Removal of Impacted Mandibular Third Molars. J Maxillofac Oral Surg. 2016;15(2):156-63.
19. Shah A, Halli R, Merchant Y, Kshirsagar R, Khurana J. Efficacy of Ketamine as an Adjunct to Local Anesthesia in the Surgical Removal of Impacted Mandibular Third Molars - A Split Mouth Prospective Controlled Clinical Study. J Clin Diagn Res. 2016;10(10):ZC29-ZC33.
20. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100.
21. Craane B, Dijkstra PU, Stappaerts K, De Laat A. One-year evaluation of the effect of physical therapy for masticatory muscle pain: a randomized controlled trial. Eur J Pain. 2012;16(5):737-47.
22. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). Cochrane, 2020. Available from www.training.cochrane.org/handbook.
23. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-6.
24. GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University, 2015 (developed by Evidence Prime, Inc.). Available from: www.gradepro.org.
25. Schünemann H, Brożek J, Guyatt G, Oxman A. GDT: G: GRADEpro Guideline Development Tool [Software]. (ed., McMaster University, 2015 (developed by Evidence Prime, Inc.), 2015,
26. Üstün Y, Erdoǧan Ö, Esen E, Karsli ED. Comparison of the effects of 2 doses of methylprednisolone on pain, swelling, and trismus after third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96(5):535-9.
27. Erhan OL, Göksu H, Alpay C, Beştaş A. Ketamine in post-tonsillectomy pain. Int J Pediatr Otorhinolaryngol. 2007;71(5):735-9.
28. Yuasa H, Sugiura M. Clinical postoperative findings after removal of impacted mandibular third molars: prediction of postoperative facial swelling and pain based on preoperative variables. Br J Oral Maxillofac Surg. 2004;42(3):209-14.
29. Buyukkurt MC, Gungormus M, Kaya O. The effect of a single dose prednisolone with and without diclofenac on pain, trismus, and swelling after removal of mandibular third molars. J Oral Maxillofac Surg. 2006;64(12):1761-6.
30. Adam F, Libier M, Oszustowicz T, Lefebvre D, Beal J, Meynadier J. Preoperative small-dose ketamine has no preemptive analgesic effect in patients undergoing total mastectomy. Anesth Analg. 1999;89(2):444-7.
31. Reeves M, Lindholm DE, Myles PS, Fletcher H, Hunt JO. Adding ketamine to morphine for patient-controlled analgesia after major abdominal surgery: a double-blinded, randomized controlled trial. Anesth Analg. 2001;93(1):116-20.
32. Dahl V, Ernoe PE, Steen T, Raeder JC, White PF. Does ketamine have preemptive effects in women undergoing abdominal hysterectomy procedures? Anesth Analg. 2000; 90(6):1419-22.
33. Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty. Anesth Analg. 2005;100(2):475-80.
34. Chia YY, Liu K, Liu YC, Chang HC, Wong CS. Adding ketamine in a multimodal patient-controlled epidural regimen reduces postoperative pain and analgesic consumption. Anesth Analg. 1998;86(6):1245-9.
35. Fu ES, Miguel R, Scharf JE. Preemptive ketamine decreases postoperative narcotic requirements in patients undergoing abdominal surgery. Anesth Analg. 1997;84(5):1086-90.
36. Menigaux C, Fletcher D, Dupont X, Guignard B, Guirimand F, Chauvin M. The benefits of intraoperative small-dose ketamine on postoperative pain after anterior cruciate ligament repair. Anesth Analg. 2000;90(1):129-35.
37. Pedersen JL, Galle TS, Kehlet H. Peripheral analgesic effects of ketamine in acute inflammatory pain. Anesthesiology. 1998;89(1):58-66.
38. Safavi M, Honarmand A, Nematollahy Z. Pre-incisional analgesia with intravenous or subcutaneous infiltration of ketamine reduces postoperative pain in patients after open cholecystectomy: a randomized, double-blind, placebo-controlled study. Pain Med. 2011;12(9):1418-26.
39. Honarmand A, Safavi M, Karaky H. Preincisional administration of intravenous or subcutaneous infiltration of low-dose ketamine suppresses postoperative pain after appendectomy. J Pain Res. 2012;5:1-6.
40. Siddiqui AS, Raees US, Siddiqui SZ, Raza SA. Efficacy of pre-incisional peritonsillar infiltration of ketamine for post-tonsillectomy analgesia in children. J Coll Physicians Surg Pak. 2013;23(8):533-7.
41. Tverskoy M, Oren M, Vaskovich M, Dashkovsky I, Kissin I. Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanism: a study in postoperative patients. Neurosci Lett. 1996;215(1):5-8.
42. Lange M, Bröking K, van Aken H, Hucklenbruch C, Bone HG, Westphal M. Einsatz von Ketamin bei Sepsis und systemischen Entzündungsreaktionen [Role of ketamine in sepsis and systemic inflammatory response syndrome]. Anaesthesist. 2006;55(8):883-91.
43. Beilin B, Rusabrov Y, Shapira Y, Roytblat L, Greemberg L, Yardeni IZ, Bessler H. Low-dose ketamine affects immune responses in humans during the early postoperative period. Br J Anaesth. 2007;99(4):522-7.
44. Mazar J, Rogachev B, Shaked G, Ziv NY, Czeiger D, Chaimovitz C, Zlotnik M, Mukmenev I, Byk G, Douvdevani A. Involvement of adenosine in the antiinflammatory action of ketamine. Anesthesiology. 2005;102(6):1174-81.
45. Cho JE, Shim JK, Choi YS, Kim DH, Hong SW, Kwak YL. Effect of low-dose ketamine on inflammatory response in off-pump coronary artery bypass graft surgery. Br J Anaesth. 2009;102(1):23-8.
46. SH Akhlagh, D Zeighami , M.B. Khosravi, B Maghsoodi, S Azemati, A Alipour. The effect of low-dose of ketamine infusion on stress responses in coronary artery bypass graft surgery. Iranian Cardiovasc Res J. 2010; 4(1): e67655
Published
2020-09-30
How to Cite
REFAHEE, Shaimaa Mohsen; AL-MORAISSI, Essam Ahmed; ALKHUTARI, Ahmed Saleh Yehya.
Pre-emptive low-dose ketamine with local anesthesia reduces postoperative morbidity after third molar surgery: A systematic review and meta-analysis..
Journal of Oral Research, [S.l.], v. 9, n. 4, p. 259-270, sep. 2020.
ISSN 0719-2479.
Available at: <https://www.joralres.com/index.php/JOralRes/article/view/joralres.2020.067>. Date accessed: 19 apr. 2024.
doi: https://doi.org/10.17126/joralres.2020.067.
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