Perineural addition of dexamethasone to 0.5% ropivacaine: a future with less pain in mandibular third molar surgery
Editorial Commentary

在神经周围0.5%罗哌卡因中加入地塞米松：下颌第三磨牙手术中减少疼痛的前景

Gustavo Henrique Mattos-Pereira, Luís Otavio Miranda Cota, Fernando Oliveira Costa

Department of Dental Clinics, Oral Pathology and Oral Surgery, Faculty of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil

Correspondence to: Gustavo Henrique Mattos Pereira. Substitute Professor of Periodontics, Department of Dental Clinics, Oral Pathology and Oral Surgery, Faculty of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil. Email: ghmattos75@gmail.com.

Comment on: Stojanović S, Burić N, Tijanić M, et al. The Assessment of Prolonged Inferior Alveolar Nerve Blockade for Postoperative Analgesia in Mandibular Third Molar Surgery by a Perineural Addition of Dexamethasone to 0.5% Ropivacaine: A Randomized Comparison Study. Int J Environ Res Public Health 2022;19:1324.

关键词：神经周围加入；地塞米松；第三磨牙手术

Received: 01 March 2023; Accepted: 24 March 2023; Published online: 31 March 2023.

doi: 10.21037/joma-23-9

长期以来，人们一直在不断地寻求在围手术期，特别是在术后，有效控制疼痛的方案。镇痛药和麻醉药的使用可以追溯到古希腊。有报道称，希波克拉底（公元前460年—公元前370年）曾使用含有镇痛和镇静物质的海绵和其他技术减轻侵入性手术的疼痛[1]。从牙科的角度来看，牙科手术产生的疼痛是牙科焦虑症出现的决定性因素，因为牙科手术直接与严重的疼痛感觉相关[2]。牙科焦虑症大大降低了患者对牙科手术治疗的依从性，也构成了麻醉学的转折点。

本文旨在评价Stojanović等人的研究[3]，他们采用了罗哌卡因联合地塞米松的治疗方案，从而更有效地减轻了下颌第三磨牙手术术后疼痛，并对疼痛程度进行了随访及评估。在一项随机、双盲的临床试验中，该研究小组的假设是：与布比卡因相比，地塞米松（一种类固醇抗炎药）和罗哌卡因（一种长效麻醉药）的联合用药方案可以明显延长麻醉时间和术后镇痛时间。这项研究设计合理，将研究对象被分为3组，每组15人。第1组患者接受加入4 mg地塞米松的0.5%罗哌卡因，第2组患者接受加入1 mL无菌0.9%盐水的0.5%罗哌卡因，第3组患者接受加入1 mL无菌0.9%盐水的0.5%布比卡因。

罗哌卡因是一种长效酰胺类局部麻醉药，经美国食品和药物管理局（Food and Drug Administration，FDA）批准用于手术麻醉和治疗急性疼痛。其使用范围非常广泛，从广泛的神经阻滞，到末梢浸润阻滞。一般而言，罗哌卡因最常用于硬膜外麻醉。罗哌卡因的作用机制包括通过抑制钠离子通道，从而可逆地抑制钠离子进入神经纤维。同时，罗哌卡因抑制钾离子通道的作用也具有剂量依赖性。这种作用可以阻断神经冲动的传导。它可以选择性地对伤害性A、B和C纤维，以及运动性A、B纤维产生阻滞作用。由于罗哌卡因对脂质的亲和力较低，其穿透大型有髓鞘运动纤维的概率很低。这一特点使其在与布比卡因等其他局部麻醉药的对比中更有优势，后者通常更亲脂。与布比卡因相比，罗哌卡因的心脏毒性和神经毒性要小得多，而且它的耐受性普遍较好[4]。寻找一种长效局部麻醉药以缓解术后疼痛，并产生低副作用是镇痛研究的主要目标之一。因此，此研究提出的结果很有代表性，特别是在罗哌卡因产生的麻醉和镇痛的持续时间方面。这些研究结果证明了在牙科手术中对这种基础麻醉药物的进一步研究是合理的。

既往文献普遍报道了使用地塞米松来减轻术后疼痛的效果和其他副作用，如在第三磨牙拔除术中患者出现牙关紧闭和水肿[5-8]。地塞米松是一种合成的糖皮质激素，具有强大的抗炎和免疫抑制作用[9]。糖皮质激素的作用机制和作用部位尚不明确。地塞米松的硬膜外给药会直接抑制来自伤害性C纤维的信号传递。此外，它还能促进局部效应的降低，诱发血管收缩，从而延长麻醉效果[10]。

与安慰剂相比，地塞米松在拔除阻生第三磨牙的手术中，在减少手术后的不良反应及减轻疼痛、水肿和牙关紧闭方面有具有积极作用[5-8]。值得注意的是，不同给药途径之间也被进行了比较，从而确定哪种途径更有效。一项临床试验比较了地塞米松的两种给药途径（局部注射和口服）对缓解第三磨牙手术的术后疼痛、水肿和牙关紧闭的疗效。研究结果发现两种给药途径的疗效相似[11]。在一项关于比较肌肉注射和黏膜下给药的系统评价中，将纳入的四项研究进行分析，结果显示两种给药途径并未存在明显的差异[12]。最近的一项网络荟萃分析评估了不同给药途径对减轻第三磨牙拔除术后后遗症的有效性，结果也同样显示地塞米松的不同给药途径之间没有显著差异[13]。

鉴于此，我们应关注Stojanović等人使用的地塞米松给药技术[3]。该技术使用一个装有1 mL地塞米松的注射器替换装有麻醉药的注射器。重要的是将针头始终保持在注射部位。这种技术要求操作人员的技能水平足够高，因为在此情况下发生针头断裂等意外的风险会增加。由于其他给药途径，如口服途径，在牙科手术的术后阶段已经显示了较好的疗效[5-9]，因此必须进行更多的研究来评估罗哌卡因和地塞米松在不同给药途径下的疗效差异。

进一步开展牙科领域的基础麻醉药物研究是减轻牙科手术创伤的重要一步，同时也能够将可能出现的相关并发症降到最低。正如Stojanović等人[3]所证明的那样，罗哌卡因是一种具有重要特性的基础麻醉药物，其在牙科手术中的应用可以得到进一步的推广。此外，使用地塞米松更有助于减少术后并发症，提高患者舒适度。值得注意的是，术后镇痛药物的用量也会相应降低，同时还可以改善需要拔除阻生第三磨牙的患者的生活质量。

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Oral and Maxillofacial Anesthesia. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-23-9/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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译者介绍
金晨昱
上海交通大学医学院博士研究生在读，现就职于上海交通大学医学院附属第九人民医院。（更新时间：2023-06-15）
审校介绍
夏明
上海交通大学医学院附属第九人民医院麻醉科副主任医师，副教授，硕士研究生导师，人工智能课题组长。Journal of Medical Artificial Intelligence（JMAI）主编，Journal of Oral and Maxillofacial Anesthesia（JOMA）执行主编，中华口腔医学会口腔麻醉专业委员会全国常务委员，中华口腔医学会镇静镇痛专委会全国常务委员，中国康复医学会疼痛康复专委会全国委员。（更新时间：2023-06-15）

（本译文仅供学术交流，实际内容请以英文原文为准。）

doi: 10.21037/joma-23-9
Cite this article as: Mattos-Pereira GH, Cota LOM, Costa FO. Perineural addition of dexamethasone to 0.5% ropivacaine: a future with less pain in mandibular third molar surgery. J Oral Maxillofac Anesth 2023;2:10.

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