Dexamethasone Role In Surgical Extraction

Published Date: 02 Nov 2017

INTRODUCTION:

The mandibular third molar is last tooth to erupt and commonly becoming impacted. Its removal is one of the most frequent surgical procedures in dentistry .1 Impacted mandibular third molars are often associated with pericoronitis, periodontitis, cystic lesions, neoplasm, pathologic root resorption and can cause detrimental effects on adjacent tooth.2

Facial swelling, pain, and trismus which are the expected sequelae of third molar. Impaction surgery is unpleasant and uncomfortable for the patients and should be minimized as much as possible. Swelling is the most common complication and it usually occur postoperatively because of tissue injuries 3,4Being a highly vascularized area of head and neck region, predominantly constituted by loose connective tissue, a series of functional and structural alterations is expected in 3rd molar surgery, that leads to the liberation of exudate and subsequent swelling, trismus and pain (9-11). To control postoperative inflammation and symptoms associated, it is necessary to provide an adequate anti-inflammatory therapy (1-15).

Reducing post-operative discomfort is of important concern, both for patients and oral surgeons. A skilled surgeon, a short operation, and the application of cold dressings have a beneficial effect on postoperative edema. 5

The use of steroid therapy to control inflammation in surgical procedures has been an area of dispute since its inception in 1948. The effective ness of Gluco-corticosteriods as an anti-inflammatory agent was first reported by Philip Showalter Hench and Edward Calvin Kendall in1949, who used cortisone to treat rheumatoid arthritis. 5, 6 Steroids reduces inflammation and effects of dexamethasone have been observed in several studies6. Dexamethasone is a long acting glucocorticod, which is used for Many inflammatory and auto immune diseases 7. The use of corticosteroids (betamethasone, dexamethasone) is another protective strategy for limiting postoperative swelling following oral surgical procedures. Because it has highest anti-inflammatory activity the dexamethasone is more effective.8Clinical trials have also supported the hypothesis that corticosteroids are effective in minimizing and preventing many post operative swelling.9

Many authors demonstrated a better effect in the control of the swelling and trismus when using steroids anti-inflammatory drugs versus non steroidal anti-inflammatory drugs hence the purpose of this study is to determine the role of dexamethasone in Mandibular third molar removal and to evaluate the anti-inflammatory effects of dexamethasone.

Objective:

The objective of this study was to determine the role of dexamethasone in mandibular third molar surgery.

DATA COLLECTION PROCEDURE:

This study was a randomized control trail conducted in Department of Oral & Maxillofacial surgery, Liaquat University of Medical & Health sciences Hyderabad / Jamshoro from January 2011 to September 2012. The Inclusion Criteria were the Age between 20-40yrs of either gender with bony impacted mandibular 3rd molars.The Exclusion Criteria were patients with Limited mouth opening less than 15mm, and clinically significant medical history ,drugs allergy, chronic use of medications that obscure assessment of the inflammatory response (antihistamines, NSAID, steroids and antidepressants), pregnant or lactating woman. Patients meeting the inclusion criteria were included in the study. The purpose, procedure, risk/benefits of the study was explained to the patients and informed consent was taken regarding their willingness and participation in the study. All selected patients were divided into two groups by using random number table. Patients in Group-A were given dexamethasone 8 mg intramuscularly before surgery and 4 mg 24 hours after surgery and Augmentin (Gsk) tablet 625mg BD and Brufen (Abbott) 400 mg TDS and patients in group-B considered as control group were given Augmentin 625 mg BD and Brufen 400 mg TDS post operatively only. The facial swelling was checked before surgery, and after 24 hours (1st day), after 48 hours (2nd day) and after 7 days and inter-incisor distance was measured by vernier calliper on every follow up .

The facial swelling was determined by measuring the distance in millimeters with flexible tape from the corner of the mouth to the tragus of ear and from the lateral canthus of the eye to the angle of the mandible. The sums of measurement were recorded as the facial size preoperatively and post operatively (Fig. 1). All the gathered information was noted and entered in a structured proforma

Results

In group A thirty patients consist of 19 males and 11 females. The mean age was 28.3 years with age range varies from 15-46years. In group B 16 males and 14 females with mean age was 27.1 years. Impacted teeth were classified according to angulation, most common impaction was mesioangular account for 45%of cases, and vertical impaction was 2nd common impaction with 31% . Table I

The mean preoperative swelling was 210 in control group and 212 in steroid group.

On 2nd day of post extraction swelling raised in both group with mean swelling on 222 in control group and 218 in steroid group on 2nd day and on On last and fallow

7th post-operative day swelling reduced 215 in control and 213 in steroid group. Statistically significant. Table II

Limited mouth opening is a common sequel in surgical extraction of mandibular 3rd molar. Preoperatively inter incisor month opening was measured in both groups and on every follow up visit mean decrease in mouth opening was subjectively measured. Table III

Table. I. DISTRIBUTION OF TWO GROUPS ACCORDING TO ANGULATION OF IMPACTION

Angulation

Mesio angular

Vertical

Disto angular

Horizontal

Total

Group A

13

10

4

3

30

Group B

14

9

5

2

30

Total

27 45%

19 31%

9 15%

5 8%

60

Table II. COMPARISON OF POST OPERATIVE SWELLING IN BOTH GROUPS

Swelling

Control group SD

Steroid SD

Before surgery

210 12

212 11

2nd day after surgery

222 15

218 1 4

7th days after surgery

215 13

213 13

Table III. comparsion of post-operative Mouth opening

Mouth opening

Control group SD

Steroid SD

Before surgery

42.2

3

43

4

2nd day after surgery

20

5

31

6

7th days after surgery

33.6

6

40.6

7

Discussion

Mandibular third molar impaction is a common problem affecting a large proportion of population. Mesioangular impaction (48%) followed by vertical (34%) was the common type in the current study. Our findings conformed with the previous reports from Pakistan,2 USA,16 Nigeria,19 China,20 Thailand21, Spain24 and Malaysia,10 where the common type was mesioangular impactions. However, a study among Jordanians found that vertical impactions were the most common (61.4%) and mesioangular were only 18%. 22 Similarly, another study in Barcelona had also reported that vertical impactions were the common type followed by mesioangular.23 It appears that mesioangular impactions are probably the commonest type and this may be due to their late development andmaturation, path of eruption and lack of space in mandible at later age

Most frequent procedures in Oral and Maxillofacial Surgery is removal of impacted third molars (1-9) which can lead to instant post-operative pain ,swelling and limited mouth opening (1-15). Decrease in mouth opening is a consequence of the postoperative swelling, and causing compression on nerves and leads to mild to severe pain (5,9,11-15).dexamethasone was chosen for the study because it has shown to be a drug of safe administration, if time and dosages are strictly followed. The employed analgesic was brufen , also a proven drug of safe administration

Trismus, measured in this study as a decrease in maximal interincisal opening, is a significant postoperative sequalae caused by the edema and swelling associated with the surgical trauma.1 Limitation of maximal mouth opening after surgery is also due, at least in part, to the associated pain. Brufen alone, which was found to provide a slight reduction of postoperative trismus, may be acting primarily by reducing patient discomfort upon opening, thereby permitting greater extension of the muscles of mastication. Although the therapeutic advantage of corticosteroid use is primarily in decreasing postoperative swelling, they have been shown to provide some pain relief.25 Conversely, the NSAIDs have been reported to provide some anti-inflammatory effects when evaluated using the third molar research model.26 It is therefore not entirely surprising that the combination of steroidal and nonsteroidal therapies was most effective in relieving postoperative pain and trismus. The fact that

the combination appears to provide some additional analgesic and anti-inflammatory benefit may also be due to their separate mechanisms along the prostaglandin cascade and therefore jointly act to limit the production of peripheral prostanoids. The time course for trismus and concurrent limitations

in oral function described in the current study are in agreement with findings of a recent large multicenter trial that indicated symptoms reach a maximum at Day 1 or Day 2 postoperatively and generally resolve by Day 7.27,28 They determined predictor factors for less favorable and more prolonged postoperative outcomes to include older age, female gender, both lower third

molars requiring bone removal, and longer procedures. 29 Our findings that trismus and postoperative

pain are minimized with the use of brufen and dexamethasone may be most advantageous when

prolonged recovery is expected.The administration of dexamethasone 1 hour IM preoperatively, combined with the postoperative administration of 400 mg of brufen on the day of the operation and the 4 postoperative days, produced a clear reduction in postoperative pain and cheek swelling after impacted third molar removal. Comparing both groups, the use of 4 mg of dexamethasone has a statistical differential between the dosages in the preoperative measures of mandible angle to latral canthus of eye, and postoperative (24 and 48 hours) in corner of mouth and Targus and inter incisal distance, demonstrating therefore the effectiveness of the medicine. Neupert et al.19 reported that mouth opening as measured by the interincisal opening pre and postoperatively was improved with 4 mg of intravenous (IV) dexamethasone in the first few days after surgery, but no difference was noted between the corticosteroid and placebo groups for pain or swelling. Twenty-four hours after surgery the restriction of mouth opening was reduced by 20% using 4 mg of dexamethasone, and 48 hours after surgery it increased to 31, showing clinical and statistic differential. Beirne and Hollander (11) reported that 125 mg of IV Methylprednisolone after third molar surgery reduced pain levels during the first postoperative day. Swelling was less with the glucocorticoid administration through postsurgery day three (3), but did not seem to be correlated with pain levels. Trismus was minimally less with the corticosteroid medication, but not related to pain levels. Dionne et al. (20) used 4 mg of dexamethasone given 12 hours before and just after third molar surgery in thirty three (33) patients, twenty eight (28) received a placebo control. As markers of the extent of inflammation, samples of prostaglandin E2 (PGE2) and thromboxane B2 (TxB2) were collected over time at the mandibular surgical sites. Dexamethasone significantly decreased the levels of PGE2 and TxB2, but had a minimal effect on reported pain on the day of surgery. In 2005 Tiwana et al. (23) reported that the administration of IV corticosteroids before third molar surgery offers a beneficial effect on health-related quality of life, we agreed with this, because having swelling and pain less the patient can return to his normal life.

Conclusion

We found that the dexamethasone was statistically more efficient in the trismus and swelling control than only antibiotic and analgesics.

In absence of contraindications for corticosteroid administration, the use of single-dose prednisolone appears to be a safe and effective method to reduce postoperative clinical symptoms in third molar surgery