|Year : 2017 | Volume
| Issue : 3 | Page : 116-121
Assessment of pain, swelling and trismus following impacted third molar surgery using injection dexamethasone submucosally: A prospective, randomized, crossover clinical study
Kamran Bokhari Syed1, Falah Hassan Khuzayyim AlQahtani1, Abdul Hakeem Ayed Mohammad1, Ismail Mohammad Abdullah1, Hussain Saad Hussain Qahtani1, Mohammad Shahul Hameed2
1 Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha, Kingdom of Saudi Arabia
2 Department of Diagnostic Sciences and Oral Biology, College of Dentistry, King Khalid University, Abha, Kingdom of Saudi Arabia
|Date of Web Publication||27-Jun-2017|
Kamran Bokhari Syed
Departments of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Background: Corticosteroids are known to reduce inflammation, fluid transudation, and edema. Secreted from the adrenal glands, these compounds have a significant role in maintaining metabolism. One of the essential roles played by steroids is their anti-inflammatory role. Aims and Objectives: This prospective, randomized, crossover, clinical study was conducted with the following aims and objectives: (a) to assess pain, swelling and trismus in patients undergoing surgical removal of impacted third molars, (b) to compare the pain, swelling and mouth opening with injection of submucosal dexamethasone 4 mg administered preoperatively, and (c) to compare the results with similar studies conducted elsewhere. Materials and Methods: The study sample involves 20 patients (40 impacted teeth-split arch) with the following inclusion criteria: Patient's reporting for surgical removal of symptomatic impacted mandibular third molars aged between 18 and 45, impacted mandibular third molar with similar anatomical position, and similar surgical difficulty (Pell-Gregory classification was followed), no allergies to medicines prescribed in the postoperative period, patients who are nonsmokers, nonalcoholics and without any systemic diseases, and not systemically compromised or not under long-term steroid therapy. Syndromic patients, patients with periapical pathologies were excluded from the study. Results: The results of the present study suggest that there is a significant reduction of pain, swelling and improvement in mouth opening following submucosal injection of dexamethasone at the end of the 1st postoperative day and the results are statistically significant. Conclusion: (a) Corticosteroids decrease pain, edema and swelling by exerting their anti-inflammatory role, (b) there is statistically significant difference in reduction of pain, swelling and improvement of mouth opening at the end of 1st postoperative day, (c) submucosal injection of dexamethasone is less traumatic, less painful and is effective in limiting postoperative discomfort to the patient, and (d) a similar prospective study is suggested comparing the efficacy of intravenous dexamethasone versus submucosal administration of dexamethasone.
Keywords: Impacted third molars, postoperative complications, steroids
|How to cite this article:|
Syed KB, AlQahtani FH, Mohammad AH, Abdullah IM, Qahtani HS, Hameed MS. Assessment of pain, swelling and trismus following impacted third molar surgery using injection dexamethasone submucosally: A prospective, randomized, crossover clinical study. J Int Oral Health 2017;9:116-21
|How to cite this URL:|
Syed KB, AlQahtani FH, Mohammad AH, Abdullah IM, Qahtani HS, Hameed MS. Assessment of pain, swelling and trismus following impacted third molar surgery using injection dexamethasone submucosally: A prospective, randomized, crossover clinical study. J Int Oral Health [serial online] 2017 [cited 2019 Aug 25];9:116-21. Available from: http://www.jioh.org/text.asp?2017/9/3/116/209058
| Introduction|| |
Impaction refers to the failure of tooth to reach normal occlusal and functional position following completion of chronological age and two-thirds root formation. Since it does not reach normal functional position, an impacted tooth is considered pathologic and requires treatment., Since the removal of impacted third molar teeth is a surgical procedure, it carries with it inherent risks and complications. Commonly associated postoperative sequelae involve pain, trismus, and swelling. These are directly related to the difficulty factor associated with impacted teeth, duration of surgery, age of the patient, expertise of the surgeon. Trismus following surgical extraction is secondarily due to pain and swelling. As stated in Starling's law, surgical trauma characterized by hyperemia, vasodilatation is due to increased capillary permeability with an accumulation of fluid in the interstitial space following increased osmotic pressure in capillaries., Corticosteroids are known to reduce inflammation, fluid transudation, and edema., Secreted from the adrenal glands, these compounds have a significant role in maintaining metabolism. One of the essential roles played by steroids is their anti-inflammatory role thereby significantly contributing in autoimmune diseases. Their anti-inflammatory role is explained by the principle of endogenous protein synthesis which blocks the enzymatic activation of phospholipase A2. This in turn blocks the release of arachidonic acid from components of cell membrane thereby finally inhibiting substances related to thromboxane such as prostaglandins and leukotrienes. More specifically, corticosteroids stabilize lysosomal membranes, decrease capillary permeability, suppress accumulation of neutrophils and macrophages at the site of inflammation., This also has a negative role by impairing phagocytosis which is essential for wound healing. Therefore, the use of exogenously administered corticosteroids must be evaluated on a case to case basis and is contraindicated in subjects with depressed immune response such as diabetic patients. Long-term exogenous administration of corticosteroids exerts a negative feedback effect upon the hypothalamic-hypophyseal-adrenal (HPA) gland axis suppressing the normal secretion of endogenous cortisol. Therefore, following major surgical procedures, corticosteroids are withdrawn gradually in a tapering dose. Some of the other side effects of corticosteroid use include peptic ulcer, metabolic effects on fluid and electrolyte balance, muscle atrophy, avascular necrosis, hypertension, and hyperglycemia.,, However, this negative impact on metabolism and its systemic effects are on long-term administration with higher doses of corticosteroids.
Surgical removal of impacted third molar is considered as a minor surgical procedure done mostly as an out-patient basis under local anesthesia. Patients are usually subjected to exogenous corticosteroids for not more than 2–3 days at lower doses which must have negligible side effects as stated earlier. Moreover, corticosteroids are usually administered as a single dose just before starting the procedure or given as a single dose immediate postoperatively. This also substantiates their usage in minor surgical procedures.
This is a prospective, cross-over, controlled, randomized study conducted to assess pain, swelling and mouth opening following submucosal administration of corticosteroids as a single dose preoperatively.
| Materials and Methods|| |
This prospective, randomized, cross-over, clinical study was conducted with the following aims and objectives: (a) to assess pain, swelling and mouth opening in patients undergoing surgical removal of impacted third molars, (b) to compare the results following injection of submucosal dexamethasone 4 mg administered preoperatively, and (c) to compare the results with similar studies conducted elsewhere.
The study sample involves 20 patients (40 impacted teeth-split arch) with the following inclusion criteria: Patient's reporting for surgical removal of symptomatic impacted mandibular third molars aged between 18 and 45, impacted mandibular third molar with similar anatomical position, and similar surgical difficulty (Pell-Gregory classification was followed), no allergies to medicines prescribed in the postoperative period, patients who are nonsmokers, nonalcoholics and without any systemic diseases, and not systemically compromised or not under long-term steroid therapy. Syndromic patients, patients with periapical pathologies were excluded from the study.
All the patients were treated in one center over a period of 6 months (August 2016–January 2017). Patients reporting to dental clinics with symptomatic impacted third molars or who had to undergo orthodontic therapy were included in the study. Cases were referred from the Oral Diagnosis clinic for the surgical procedure. An informed consent (duly approved by the institutional and research committee: SRC/EH/2016-17/003), verbally and a written self-declaration was obtained and documented for: (a) placing the graft (b) obtaining venous blood for processing platelet-rich plasma and using it in their extraction site. Patients who were not convinced or not willing to be part of the study sample were still treated for surgical removal of impacted teeth but were excluded from the study group. Autologous venous blood was decoded and given a number which was entered into a chart to avoid mixing up of samples.
Surgical procedure and drug administration were done by the same surgeon. All the patients were subjected to similar nerve block technique (Inferior alveolar, lingual, and long buccal nerve blocks), similar incision and flap design (Wartz incision) and simple interrupted closure performed with 3-0 mersilk. All the subjects were prescribed a 5 days course of antibiotic and analgesic.
Swelling was assessed with a measuring tape using the following landmarks: Point A: From tragus of ear to angle of mouth and Point B: From lateral canthus of eye to angle of mouth. The reading was recorded in a chart in millimeters. Mouth opening was assessed by recording inter-incisal mouth opening and pain was subjectively evaluated on visual analog scale (0–10). All the readings were recorded pre- and post-operatively at the end of 1 h, 1 day, and 1 week. Four weeks' time interval was standardized for all subjects to undergo the other side (split–arch) surgical removal.
| Results|| |
The results were entered into an excel spreadsheet, mean values were obtained and results displayed as tables and graphs. Statistical analysis was done by SPSS software version (Bioss-ISO-2001 certififed) 16 to assess the significance (P value) through Student's t-test. Results were compared and analyzed for statistical significance.
As shown in [Table 1] and [Graph 1], the pain was significantly reduced at the end of 1 day on the side administered with submucosal injection of dexamethasone. There was no significant difference in relief of pain between control and study group at the end of 1 h and the end of 1 week.
|Table 1: Comparison of pain visual analog scores within group by repeated measures ANOVA and between groups by Student's t-test|
Click here to view
[Table 2] and [Graph 2] show that there is a significant difference in reduction of swelling between the control and study groups at the end of 1 h and at the end of 1 day. However, at the end of 1 week, there is no statistical difference between the two groups.
|Table 2: Comparison of swelling scores within group by repeated measures ANOVA and between groups by Student's t-test|
Click here to view
[Graph 3] and [Table 3] show that there is an improvement in mouth opening 1 day postoperatively in the study group and the difference is statistically significant as compared to control group.
|Table 3: Comparison of mouth opening scores within group by repeated measures ANOVA and between groups by Student's t-test|
Click here to view
[Graph 4] shows a comparison of mean scores for pain, mouth opening and swelling between study group and control group as assessed statistically.
[Table 4] shows a consolidated analysis of results comparing study group and control group; wherein at the end of the 1st postoperative day, there is a significant reduction in pain, swelling, and improvement in mouth opening.
| Discussion|| |
Surgical intervention disturbs the normal fascial barriers and tends to accumulate fluid by transudation in the interstitial fluid compartment. The amount of edema is directly proportional to the extent of tissue injury, duration of surgery, and the percentage of connective tissue in the operative field. Pain is a subjective experience and is influenced by factors such as age, sex, anxiety levels, and also the surgical difficulty. Corticosteroids are endocrine secretions from the adrenal glands. They have an effect on almost all the systems of the body, and their secretion is regulated by secretion from the anterior pituitary hormone namely adrenocorticotrophic hormone (ADCH) through a negative HPA axis. Corticosteroids limit inflammatory mediators and thus lessen fluid transudation and edema., Corticosteroids decrease capillary permeability, stabilize lysosomal membranes, and inhibit the release of proteolytic enzymes thereby reducing edema. Effect of corticosteroids on reducing swelling, pain, and trismus is vast in the literature. However, most of the studies focus on oral or parenteral (intramuscular/intravenous) route of administration. Few studies have discussed in detail the submucosal role and its benefits in reducing the postoperative sequelae of third molar impaction. Noboa et al., in their prospective, controlled, and crossover study evaluated submucosal effect of dexamethasone with the oral route. They concluded that both routes were effective to control pain, edema, and trismus presenting similar results. In our opinion, oral dexamethasone is not advisable for minor oral surgery procedures like impacted third molar removal. This is because of the fact that plasma half-life of oral dexamethasone is 3–4.5 h and biological half-life is 36–54 h. The onset of action is delayed, and by then surgical edema will set in. As stated widely in literature and textbooks, the most effective period for administration of a corticosteroid is before the edema develops, that is the time of surgical intervention/trauma.
Beirne in their systemic review involving 28 studies to assess the effect of corticosteroids on impacted third molars stated that these agents reduce the degree of trismus and inflammation. Antunes et al., in their prospective, controlled, randomized trial involving 60 impacted third molars comparatively evaluated pain, edema, and trismus following local injection and tablets of dexamethasone. They concluded that both the oral and local injection of dexamethasone are effective and produced similar results. Herrera-Briones et al., in their systemic search of literature to assess the role of corticosteroids in third molar surgery stated that greater effects are achieved following parenteral route of administration before the surgery. Studies conducted by several authors involving either intramuscular or intravenous injection of dexamethasone or betamethasone produced similar results in reducing either pain, edema, and trismus or a combination of these variables.,,,,,,,,,,, None of these studies evaluated submucosal route of injection to assess the postsurgical variables involved in this study. Mirza Abdul Rauf conducted a study among 100 patients to assess the benefits of steroids following surgical extraction of the third molar by administering a combination of intravenous dexamethasone and hydrocortisone. Ngeow and Lim conducted a review involving 34 articles to assess the efficacy of corticosteroids following third molar surgery. Based on their review, the authors concluded that swelling and trismus have a significant impact while reduction of pain following administration of steroids is still debatable. Ehsan et al., conducted a randomized controlled trial involving 100 patients to assess swelling and trismus and concluded that submucosal injection of 4 mg dexamethasone is effective.
A noninterventional comparative study was conducted by Selimovic et al., by oral administration of methyl prednisolone to assess trismus following third molar extraction. Their results suggested that combination of nonsteroidal anti-inflammatory drugs and oral steroid had better control on postoperative trismus. Sabhlok et al. compared the efficacy of steroid by injecting dexamethasone in the submasseteric muscle. Their results were contradictory to most of the earlier studies as they suggested that oral route is superior to intramuscular route in controlling trismus. Vivek et al., recently conducted a study comparing the efficacy of dexamethasone following all three routes of administration, intravenous, intramassetric, and submucosal. Their results reflected that trismus has better control through intramassetric administration, whereas pain and swelling had better response to intravenous route of administration with dexamethasone.
In our opinion, intravenous route of administration though definitely achieves desirable results; it requires expertise, is painful and if the solution is deposited in surrounding subcutaneous tissue causing intense pain and inflammation. Therefore, if a less traumatic route such as submucosal injection produces similar effects, we advise submucosal injection of dexamethasone to limit edema, pain, and trismus. The results of the present study suggest that there is a significant reduction of pain, swelling, and improvement in mouth opening following submucosal injection of dexamethasone at the end of the 1st postoperative day and the results are statistically significant.
We also suggest that a prospective study with larger sample size be conducted for better assessment, cone beam computed tomography be used assessment of bone formation, and a comparison be made between intra-muscular injection of dexamethasone and submucosal injection on a split arch basis for surgical removal of impacted third molars.
| Conclusion|| |
- Corticosteroids decrease pain, edema, and swelling by exerting their anti-inflammatory role
- There is statistically significant difference in reduction of pain, swelling, and improvement of mouth opening at the end of 1st postoperative day
- Submucosal injection of dexamethasone is less traumatic, less painful, and is effective in limiting postoperative discomfort to the patient
- A similar prospective study is suggested comparing the efficacy of intravenous dexamethasone versus submucosal administration of dexamethasone.
The authors would like to thank Dr. Shreyas Tikare, Assistant Professor, Preventive and Community Dentistry for his valuable guidance in statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Syed KB, Zaheer KB, Ibrahim M, Bagi MA, Assiri MA. Prevalence of impacted molar teeth among Saudi population in Asir Region, Saudi Arabia – A retrospective study of 3 years. J Int Oral Health 2013;5:43-7.
Frost DE, Hersh EV, Levin LM. Management of impacted teeth. In: R Fonseca, editor. Oral and Maxillofacial Surgery. Vol. I. Philadelphia: Saunders; 2000. p. 245-80.
Messer EJ, Keller JJ. The use of intraoral dexamethasone after extraction of mandibular third molars. Oral Surg Oral Med Oral Pathol 1975;40:594-8.
Beirne OR, Hollander B. The effect of methylprednisolone on pain, trismus, and swelling after removal of third molars. Oral Surg Oral Med Oral Pathol 1986;61:134-8.
Beirne OR. Evaluation dexamethasone for reduction of postsurgical sequel of third molar removal. J Oral Maxillofac Surg 1992;50:1182-3.
Patten JR, Patten J, Hutchins MO. Adjunct use of dexamethasone in postoperative dental pain control. Compendium 1992;13:580, 582, 584.
Barron RP, Benoliel R, Zeltser R, Eliav E, Nahlieli O, Gracely RH. Effect of dexamethasone and dipyrone on lingual and inferior alveolar nerve hypersensitivity following third molar extractions: Preliminary report. J Orofac Pain 2004;18:62-8.
Das JR, Sreejith VP, Anooj PD, Vasudevan A. Use of corticosteroids in third molar surgery: Review of literature. Univ Res J Dent 2015;5:171-5. [Full text]
Chaudhary PD, Rastogi S, Gupta P, Niranjanaprasad Indra B, Thomas R, Choudhury R. Pre-emptive effect of dexamethasone injection and consumption on post-operative swelling, pain, and trismus after third molar surgery. A prospective, double blind and randomized study. J Oral Biol Craniofac Res 2015;5:21-7.
Chuc NT, Larsson M, Do NT, Diwan VK, Tomson GB, Falkenberg T. Improving private pharmacy practice: A multi-intervention experiment in Hanoi, Vietnam. J Clin Epidemiol 2002;55:1148-55.
Zandi M. Comparison of corticosteroids and rubber drain for reduction of sequelae after third molar surgery. Oral Maxillofac Surg 2008;12:29-33.
Kang SH, Choi YS, Byun IY, Kim MK. Effect of preoperative prednisolone on clinical postoperative symptoms after surgical extractions of mandibular third molars. Aust Dent J 2010;55:462-7.
Capuzzi P, Montebugnoli L, Vaccaro MA. Extraction of impacted third molars. A longitudinal prospective study on factors that affect postoperative recovery. Oral Surg Oral Med Oral Pathol 1994;77:341-3.
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.
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.
Noboa MM, Ramacciato JC, Teixeira RG, Vicentini CB, Groppo FC, Lopes Motta RH. Evaluation of effects of two dexamethasone formulations in impacted third molar surgeries. Rev Dor São Paulo 2014;15:163-8.
Beirne OR. Corticosteroids decrease pain, swelling and trismus. Evid Based Dent 2013;14:111.
Antunes AA, Avelar RL, Martins Neto EC, Frota R, Dias E. Effect of two routes of administration of dexamethasone on pain, edema, and trismus in impacted lower third molar surgery. Oral Maxillofac Surg 2011;15:217-23.
Herrera-Briones FJ, Prados Sánchez E, Reyes Botella C, Vallecillo Capilla M. Update on the use of corticosteroids in third molar surgery: Systematic review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:e342-51.
Huffman GG. Use of methylprednisolone sodium succinate to reduce postoperative edema after removal of impacted third molars. J Oral Surg 1977;35:198-9.
Hargreaves KM, Schmidt EA, Mueller GP, Dionne RA. Dexamethasone alters plasma levels of beta-endorphin and postoperative pain. Clin Pharmacol Ther 1987;42:601-7.
Skjelbred P, Løkken P. Reduction of pain and swelling by a corticosteroid injected 3 hours after surgery. Eur J Clin Pharmacol 1982;23:141-6.
ElHag M, Coghlan K, Christmas P, Harvey W, Harris M. The anti-inflammatory effects of dexamethasone and therapeutic ultrasound in oral surgery. Br J Oral Maxillofac Surg 1985;23:17-23.
Pederson A. Decadronphosphate in the relief of complaints after third molar surgery. Int J Oral Maxillofac Surg 1985;14:235.
Milles M, Desjardins PJ. Reduction of postoperative facial swelling by low-dose methylprednisolone: An experimental study. J Oral Maxillofac Surg 1993;51:987-91.
Sisk AL, Bonnington GJ. Evaluation of methylprednisolone and flurbiprofen for inhibition of the postoperative inflammatory response. Oral Surg Oral Med Oral Pathol 1985;60:137-45.
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.
Schmelzeisen R, Frölich JC. Prevention of postoperative swelling and pain by dexamethasone after operative removal of impacted third molar teeth. Eur J Clin Pharmacol 1993;44:275-7.
Rauf MA. The benefits of steroids therapy in surgical extraction of mandibular third molar. Pak J Med Health Sci 2015;9:1019-21.
Ngeow WC, Lim D. Do corticosteroids still have a role in the management of third molar surgery? Adv Ther 2016;33:1105-39.
Ehsan A, Ali Bukhari SG, Ashar, Manzoor A, Junaid M. Effects of pre-operative submucosal dexamethasone injection on the postoperative swelling and trismus following surgical extraction of mandibular third molar. J Coll Physicians Surg Pak 2014;24:489-92.
Selimovic E, Ibrahimagic-Šeper L, Šišic I, Sivic S, Huseinagic S. Prevention of trismus with different pharmacological therapies after surgical extraction of impacted mandibular third molar. Med Glas (Zenica) 2017;14:145-51.
Sabhlok S, Kenjale P, Mony D, Khatri I, Kumar P. Randomized controlled trial to evaluate the efficacy of oral dexamethasone and intramuscular dexamethasone in mandibular third molar surgeries. J Clin Diagn Res 2015;9:ZC48-51.
Vivek GK, Vaibhav N, Shafath A, Imran M. Efficacy of intravenous, intramassetric, and submucosal routes of dexamethasone administration after impacted third molar surgery: A randomized, comparative clinical study. J Adv Clin Res Insights 2017;4:3-7.
[Table 1], [Table 2], [Table 3], [Table 4]