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 Table of Contents  
ORIGINAL RESEARCH
Year : 2017  |  Volume : 9  |  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


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 Publication27-Jun-2017

Correspondence Address:
Kamran Bokhari Syed
Departments of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_65_17

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  Abstract 

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 Nov 19];9:116-21. Available from: http://www.jioh.org/text.asp?2017/9/3/116/209058


  Introduction Top


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.[1],[2] 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.[3],[4] Corticosteroids are known to reduce inflammation, fluid transudation, and edema.[5],[6] 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.[7] More specifically, corticosteroids stabilize lysosomal membranes, decrease capillary permeability, suppress accumulation of neutrophils and macrophages at the site of inflammation.[8],[9] 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.[10],[11],[12] 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 Top


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 Top


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

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[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

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[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

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[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.
Table 4: Comparative assessment of pain, swelling, and trismus

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  Discussion Top


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.[13] 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.[14],[15] 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.[16] Noboa et al., in their prospective, controlled, and crossover study evaluated submucosal effect of dexamethasone with the oral route.[16] 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.[17] 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.[18] 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.[19] 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.[3],[4],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] 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.[29] 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.[30] 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.[31]

A noninterventional comparative study was conducted by Selimovic et al., by oral administration of methyl prednisolone to assess trismus following third molar extraction.[32] 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.[33] 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.[34]

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 Top


  1. Corticosteroids decrease pain, edema, and swelling by exerting their anti-inflammatory role
  2. There is statistically significant difference in reduction of pain, swelling, and improvement of mouth opening at the end of 1st postoperative day
  3. Submucosal injection of dexamethasone is less traumatic, less painful, and is effective in limiting postoperative discomfort to the patient
  4. A similar prospective study is suggested comparing the efficacy of intravenous dexamethasone versus submucosal administration of dexamethasone.


Acknowledgments

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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