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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 35-38

Postoperative evaluation, after surgical removal of mandibular third molar, with and without local administration of injection dexamethasone 8 mg: A comparative study


1 Registrar, Department of Oral and Maxillofacial Surgery, Ministry of Health, Al-Amiri Dental Center, Kuwait
2 Senior Practitioner, Department of Oral and Maxillofacial Surgery, Ministry of Health, Al-Amiri Dental Center, Kuwait
3 Registrar, Department of Periodontology and Implantology, Ministry of Health, Al-Jahra Specialty Dental Center, Kuwait
4 Reader, Department of Periodontology and Implantology, Pushpagiri College of Dental Science, Thiruvalla, Kerala, India
5 Senior Lecturer, Department of Periodontology and Implantology, St Gregorios Dental College, Chelad, Kerala, India

Date of Web Publication25-Sep-2019

Correspondence Address:
Dr. Nithin Mathew Cherian
Al-Amiri Dental Center, Ministry of Health, Kuwait City
Kuwait
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INPC.INPC_30_19

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  Abstract 


Aim: The aim of the study is to evaluate the relative ability of 8 mg dose of intraoperative dexamethasone, to reduce the postoperative discomfort after third molar surgery.
Materials and Methods: A total of sixty patients required surgical removal of a single mandibular third molar. Two operators concluded the study on sixty patients with an impacted third molar, with each operator having thirty patients, of which 15 were administered injection dexamethasone 8 mg at the site of surgery 30 min prior to the surgical removal of the impacted tooth. The maximum interincisal distance and facial contours were measured at baseline and at postsurgery days 1 and 7 to check edema.
Results: None of the patients developed wound infection or any serious postoperative complications. It was observed that the patients with intravenous steroids had very minimal postoperative swelling (within Grade 1) compared to the Sample B (Grades 2 and 3), but the bleeding and postoperative pain after 24 h were slightly more compared to the Sample B, wound healing was much delayed and suture removal on the 12th day.
Conclusion: Dexamethasone (8 mg) is effective in reducing postoperative discomfort after third molar surgeries.

Keywords: Corticosteroids, extraction, postoperative edema, randomized controlled trial, submucosal route


How to cite this article:
Cherian NM, George AJ, Panackel AS, Sman RR, Issac AV. Postoperative evaluation, after surgical removal of mandibular third molar, with and without local administration of injection dexamethasone 8 mg: A comparative study. Int J Prev Clin Dent Res 2019;6:35-8

How to cite this URL:
Cherian NM, George AJ, Panackel AS, Sman RR, Issac AV. Postoperative evaluation, after surgical removal of mandibular third molar, with and without local administration of injection dexamethasone 8 mg: A comparative study. Int J Prev Clin Dent Res [serial online] 2019 [cited 2019 Nov 13];6:35-8. Available from: http://www.ijpcdr.org/text.asp?2019/6/2/35/267796




  Introduction Top


Extraction of impacted lower third molars are the most common operative procedure in oral surgery and usually produces pain, trismus, and facial swelling in the postoperative period.[1] Surgical removal of impacted third molars involves trauma to soft and bony tissue and can result in considerable pain, swelling, and trismus. These postoperative sequelae can cause distress to the patient and affect the patient's quality of life after surgery.[2] Usage of corticosteroids as anti-inflammatory agents in dental practice began back in the 1950's with the administration of hydrocortisone to prevent inflammation in oral surgery. A single glucocorticoid dose inhibits the synthesis and/or release of pro-inflammatory and inflammatory mediators in a variety of surgical procedures, with a reduction of fluid transudation and therefore edema. This effect is well known and has been widely used to reduce swelling associated with the surgical extraction of impacted third molars. Prolonged corticosteroid use can delay healing and increase patient susceptibility to infection. The glucocorticoids most widely used in oral surgery are dexamethasone Post-operative (PO), dexamethasone sodium phosphate (intravenous [IV] and intramuscular), dexamethasone acetate (intramuscular), methylprednisolone (PO), and methylprednisolone acetate and methylprednisolone sodium succinate (IV and intramuscular). Postoperative swelling and edema may be due in part to the conversion of phospholipids into arachidonic acid by phospholipase A2, and the resultant synthesis of prostaglandins (PGs), leucotrienes, or thromboxane-related substances act as mediators of the inflammatory response. These symptoms are not observed immediately after surgery, but rather begin gradually, peaking 2 days after the extraction. Corticosteroids such as dexamethasone may inhibit the initial step in this process and have been extensively used in varying regimens and routes to lessen inflammatory sequelae after third molar surgery.[3],[4],[5] Therefore, the present comparative study was conducted for postoperative evaluation, after surgical removal of mandibular third molar, with and without local administration of injection dexamethasone 8 mg.


  Materials and methods Top


In this study, a total of sixty patients requiring surgical removal of a single mandibular third molar, under local anesthesia were selected from the Department of Oral and Maxillofacial Surgery. The oral hygiene statuses of each of these patients were well maintained with full mouth scaling and prophylaxis. Basic blood investigations, osteoprotegerin, and informed consent were received from each patient. Mesioangular impacted mandibular third molars, with Winter's classification; teeth in Classes 1 and 11 and position A and B in Pell and Gregory, all teeth with complete root formation. After ethical approval, the purpose and design of the study was verbally explained to the patients and written informed consent was obtained, the group of sixty patients in the age between 22 and 35, were split into two groups and simultaneously treated by two surgeons under the same working environment using the conventional tooth-splitting technique with modified envelope flap incision. Out of all sixty patients, thirty patients were (Sample A) administered IV injection dexamethasone 30 min before the procedure, while the other thirty patients (Sample B) underwent the procedures without IV steroids. All patients were given premedication with Amoxicillin 500 mg 1 h before surgical procedure. 2.5 ml solution of lignocaine with 1:200,000 concentrations of adrenaline was used for the mandibular nerve block using 24 gauge needle and blade no 15 used for incisions. Tooth sectioning done with 702 size bur and wound closure done with 3.0 silk after irrigation of the extracted socket was done with 1:1 ratio normal saline and betadine solution. An initial follow-up after 24 h was evaluated and a subsequent review after 7 and 12 days were also evaluated. The evaluation parameters are postoperative swelling, bleeding, pain, and wound healing. Swelling was to evaluate with three imaginary lines and the lower border of the mandible, which is described as in [Figure 1]. Swelling was evaluated after 24 h as Grade 1 (swelling within the borders described), Grade 2 (swelling intersecting the border lines), and Grade 3 (swelling crossing the borderline). Postoperative bleeding after 12 h was evaluated from 1 to 5 as per the patients. Pain was evaluated after 24 h from 1 to 5 as per the patients. Wound healing was evaluated on the 7th postoperative day.
Figure 1: Mandibular image Line A: Occlusal plane, Line B: Imaginary line drawn 2 cm anteriorly to the line perpendicular to the occlusal plane (Line A) to the mandibular gonial notch, Line C: Imaginary line drawn 2 cm posteriorly to the line perpendicular to the occlusal plane (Line A) to the mandibular gonial notch

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  Results Top


The purpose of the study was to evaluate the postsurgical complications of surgically removed mandibular third molar with and without the administration of IV injection dexamethasone 8 mg stat 30 min prior to surgery. At follow-up, no patients developed wound infection or serious postoperative complications. It was observed that the patients with IV steroids had very minimal postoperative swelling (within Grade 1) compared to the Sample B (Grades 2 and 3), but the bleeding and postoperative pain after 24 h were slightly more compared to the Sample B, wound healing was much delayed and suture removal was carried only on the 12th day.


  Discussion Top


The surgical removal of third molars is often associated with severe postoperative discomfort, even when teeth are removed using a gentle surgical technique.[4] Thus, many clinicians have attempted to reduce the postsurgical sequelae by using anti-inflammatory drugs.[5] The anti-inflammatory efficacy of corticosteroids has led to their widespread use when third molars are removed.[6],[7] Corticosteroids such as dexamethasone and methylprednisolone have been used extensively in the dentoalveolar surgery due to their nearly pure glucocorticoid effects, virtually no mineralocorticoid effects, and the least adverse effects on leucocyte chemotaxis.[8] Literature is rich with reports of the parenteral corticosteroid use in oral surgery, but data on the intraoral and submucosal administration route are scarce. Only one study has reported regarding the submucosal administration, and the investigators has noted limited responses to single low doses of steroids.[9] A study reported no benefit after administration of 8 mg of IV dexamethasone immediately before surgery, and such a dosage is widely recognized as subtherapeutic.[10] In contrast, Messer and Keller noted a predictable decrease in postoperative discomfort by using 4 mg of intramuscular dexamethasone immediately after surgery. In a well-conducted trial with patients serving as their own control, the effect of dentoalveolar application of two different doses of dexamethasone powder (4 and 10 mg) and submucosal injection of dexamethasone 4 mg, in 43 patients undergoing bilateral surgical extraction of lower third molars were investigated.[11] With regard to the edema analysis, each treatment subgroup showed a reduced postoperative degree of edema compared with the control group, which was as highly significant on the 2nd postoperative day as after 1 week. Moreover, from this study, no significant difference was observed between treatment regimens. Similar findings were found in the present study, the submucosal administration of dexamethasone 8 mg resulted in a highly significant decrease in edema on the 2nd postoperative day. Corticosteroids are primarily used after surgical procedures for suppressing tissue mediators of inflammation, thereby reducing transudation of fluids and lessening edema.[12],[13] Although some reduction of postoperative pain generally accompanies a reduction of edema, steroids alone do not have a clinically significant analgesic effect. In a recent study, it has been shown that dexamethasone administered in a dose of 8 mg orally at 12 h and 4 mg intravenously, 1 h before third molar surgery does not suppress PGE2 release sufficiently to produce analgesia after anesthetic offset.[14] It has also been stated that the administration of a glucocorticoid for analgesia after minor surgery such as the removal of impacted third molars is not indicated. Like previous reports,[6],[15] our data were unable to show that administration of a steroid significantly reduced pain. Moreover, the perioperative treatment with a corticosteroid had a limited and nonsignificant effect on trismus when compared with the control group at the two times of evaluation.[10]

Tissue injury from any source almost always evokes an inflammatory response. Five stages of inflammations have been described, and it has been reported that glucocorticoids are capable of blocking all the steps in the inflammatory response. They inhibit PG synthesis by blocking arachidonic acid, from cell membrane phospholipids.[13],[16] It was observed that the patients with IV steroids had very minimal postoperative swelling (within Grade 1) compared to the Sample B (Grades 2 and 3), but the bleeding and postoperative pain after 24 h were slightly more compared to the Sample B, wound healing was much delayed and suture removal was carried on the 12th day.


  Conclusion Top


The results of this study provide a basis for the administration of corticosteroids such as dexamethasone sodium phosphate in 8 mg doses to achieve reduction of postoperative edema comparable with or greater than other routes of administration. Presumably, injection of low-dose dexamethasone in the surgical site achieves a higher effective drug concentration at the site of injury without loss due to distribution to other compartments or the onset of elimination. Moreover, when surgical removal of the third molar is performed under local anesthesia, it is convenient for both the surgeon and the patient to use the submucosal route, as effectiveness of the oral administration route depends on patient compliance, and repeated dose is required to maintain adequate blood levels during the postoperative period. Administration of dexamethasone (8 mg) is effective in reducing postoperative discomfort after third molar surgeries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Grossi GB, Maiorana C, Garramone RA, Borgonovo A, Creminelli L, Santoro F, et al. Assessing postoperative discomfort after third molar surgery: A prospective study. J Oral Maxillofac Surg 2007;65:901-17.  Back to cited text no. 1
    
2.
Grossi GB, Maiorana C, Garramone RA, Borgonovo A, Beretta M, Farronato D, et al. Effect of submucosal injection of dexamethasone on postoperative discomfort after third molar surgery: A prospective study. J Oral Maxillofac Surg 2007;65:2218-26.  Back to cited text no. 2
    
3.
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;38:480-7.  Back to cited text no. 3
    
4.
Phillips C, White RP Jr., Shugars DA, Zhou X. Risk factors associated with prolonged recovery and delayed healing after third molar surgery. J Oral Maxillofac Surg 2003;61:1436-48.  Back to cited text no. 4
    
5.
Petersen JK, Hansson F, Strid S. The effect of an ibuprofen-codeine combination for the treatment of patients with pain after removal of lower third molars. J Oral Maxillofac Surg 1993;51:637-40.  Back to cited text no. 5
    
6.
Hyrkäs T, Ylipaavalniemi P, Oikarinen VJ, Paakkari I. A comparison of diclofenac with and without single-dose intravenous steroid to prevent postoperative pain after third molar removal. J Oral Maxillofac Surg 1993;51:634-6.  Back to cited text no. 6
    
7.
Schultze-Mosgau S, Schmelzeisen R, Frölich JC, Schmele H. Use of ibuprofen and methylprednisolone for the prevention of pain and swelling after removal of impacted third molars. J Oral Maxillofac Surg 1995;53:2-7.  Back to cited text no. 7
    
8.
Dionne RA, Gordon SM, Rowan J, Kent A, Brahim JS. Dexamethasone suppresses peripheral prostanoid levels without analgesia in a clinical model of acute inflammation. J Oral Maxillofac Surg 2003;61:997-1003.  Back to cited text no. 8
    
9.
Milles M, Desjardins PJ. Reduction of postoperative facial swelling by low-dose methylprednisolone: An experimental study. J Oral Maxillofac Surg 1993;51:987-91.  Back to cited text no. 9
    
10.
Neupert EA 3rd, Lee JW, Philput CB, Gordon JR. Evaluation of dexamethasone for reduction of postsurgical sequelae of third molar removal. J Oral Maxillofac Surg 1992;50:1177-82.  Back to cited text no. 10
    
11.
Graziani F, D'Aiuto F, Arduino PG, Tonelli M, Gabriele M. Perioperative dexamethasone reduces post-surgical sequelae of wisdom tooth removal. A split-mouth randomized double-masked clinical trial. Int J Oral Maxillofac Surg 2006;35:241-6.  Back to cited text no. 11
    
12.
Esen E, Taşar F, Akhan O. Determination of the anti-inflammatory effects of methylprednisolone on the sequelae of third molar surgery. J Oral Maxillofac Surg 1999;57:1201-6.  Back to cited text no. 12
    
13.
Gersema L, Baker K. Use of corticosteroids in oral surgery. J Oral Maxillofac Surg 1992;50:270-7.  Back to cited text no. 13
    
14.
Troullos ES, Hargreaves KM, Butler DP, Dionne RA. Comparison of nonsteroidal anti-inflammatory drugs, ibuprofen and flurbiprofen, with methylprednisolone and placebo for acute pain, swelling, and trismus. J Oral Maxillofac Surg 1990;48:945-52.  Back to cited text no. 14
    
15.
Sekhar CH, Narayanan V, Baig MF. Role of antimicrobials in third molar surgery: Prospective, double blind, randomized, placebo-controlled clinical study. Br J Oral Maxillofac Surg 2001;39:134-7.  Back to cited text no. 15
    
16.
Montgomery MT, Hogg JP, Roberts DL, Redding SW. The use of glucocorticosteroids to lessen the inflammatory sequelae following third molar surgery. J Oral Maxillofac Surg 1990;48:179-87.  Back to cited text no. 16
    


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