See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/47633958

Effect of submucosal and intramuscular dexamethasone on postoperative

sequelae after third molar surgery: Comparative study

Article in British Journal of Oral and Maxillofacial Surgery · October 2010

DOI: 10.1016/j.bjoms.2010.09.021 · Source: PubMed

CITATIONS READS

102 1,538

2 authors, including:

Omer Waleed Majid

University of Mosul
19 PUBLICATIONS 452 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Dexamethasone in impacted lower third molar surgery View project

Oral surgery View project

All content following this page was uploaded by Omer Waleed Majid on 02 April 2018.

The user has requested enhancement of the downloaded file.

 Available online at www.sciencedirect.com

British Journal of Oral and Maxillofacial Surgery 49 (2011) 647–652

Effect of submucosal and intramuscular dexamethasone on

postoperative sequelae after third molar surgery:
comparative study
Omer Waleed Majid ∗ , Waseem Khalid Mahmood
Department of Oral and Maxillofacial Surgery, College of Dentistry, University of Mosul, Mosul, Nineveh, Iraq

Accepted 27 September 2010

Available online 29 October 2010

Abstract

We compared the effects of dexamethasone sodium phosphate given submucosally and intramuscularly on postoperative complications after
removal of impacted lower third molars in a preliminary randomised prospective clinical trial. Thirty patients, each of whom required removal
of a single impacted mandibular third molar under local anaesthesia, were randomly allocated to one of 3 groups of 10 each. The 2 experimental
groups were given dexamethasone 4 mg submucosally or intramuscularly, and the control group had no steroid. Facial swelling and maximal
interincisal distance were measured by an independent examiner at baseline (preoperatively), and at 1, 3, and 7 days postoperatively. Pain was
measured by counting the number of rescue analgesic tablets taken, and from the patients’ response to a visual analogue scale (VAS). The
mean age of the 16 men and 14 women was 27 years (range 20–48). Both dexamethasone groups showed significant reductions in swelling
(p < 0.001) and in pain (p < 0.05) compared with the control group at all intervals. Submucosal dexamethasone resulted in significantly less
trismus than controls on day 1 postoperatively (p = 0.04), but there were no significant differences among the groups at the other times. The
effects of the two routes of dexamethasone were comparable for all variables. There were no cases of alveolar osteitis or wound infection.
Dexamethasone 4 mg given submucosally is an effective way of minimising swelling, trismus, and pain after removal of impacted lower
third molars, and is comparable with the intramuscular route. It offers a simple, safe, painless, non-invasive, and cost-effective treatment in
moderate and severe cases.
© 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Corticosteroids; Submucosal dexamethasone; Third molar surgery

Introduction These agents act by inhibiting the body’s inflammatory

response to injury through various mechanisms, with a reduc-
The removal of lower third molars is still the most common tion of fluid transudation and therefore oedema.2,3
surgical procedure done by oral and maxillofacial surgeons.1 Over several decades many studies have reported the effec-
It is often associated with swelling, pain, and trismus as a tiveness of corticosteroids given before or just after removal
result of the postoperative inflammatory response, and these of third molars in improving recovery.2,4–11 The method of
can have a serious impact on the patient’s quality of life, as use, however, has varied, and the most effective regimen has
well as having financial consequences. yet to be defined.
To reduce postoperative complications, therefore, seems a Different routes have been used. Given intramuscularly a
logical goal, particularly if healing is not compromised, and single preoperative or postoperative dose gives good plasma
the use of corticosteroids has gained wide acceptance. concentrations of the drug and prolonged anti-inflammatory
action.7 It is the most commonly prescribed route in our prac-
∗
tice, as it is quicker to take effect than when given orally, and
Corresponding author. Tel.: +964 60 812910; fax: +964 60 812950.
long-acting depot preparations can be injected.
E-mail address: omerw majid@yahoo.co.uk (O.W. Majid).

0266-4356/$ – see front matter © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.09.021
648 O.W. Majid, W.K. Mahmood / British Journal of Oral and Maxillofacial Surgery 49 (2011) 647–652

We found few reports of corticosteroids given in the region

adjacent to the site of operation, and these gave encour-
aging results compared with controls.12–15 The technique
is convenient for the surgeon, as the injection is given in
close proximity to the operative field, and for the patient, as
the injection is given into an anaesthetised area. However,
we could find no study that compared the effect of locally
injected corticosteroids with those given by other routes.
This prospective study was designed to compare the effect
of dexamethasone injected submucosally (near the surgical
site) with that of the same dose given intramuscularly, both
immediately after operation, on the postoperative sequelae
after removal of impacted lower third molars. Fig. 1. Submucosal injection of dexamethasone.

Patients and methods (Dexa-Allvoran® , TAD Pharma GmbH, Legmo, Germany) as

submucosal and intramuscular injections, respectively. Both
This randomised prospective study was conducted at the injections were given immediately postoperatively. Dexam-
Department of Oral and Maxillofacial Surgery, College of ethasone was injected submucosally into the buccal vestibule
Dentistry, University of Mosul, and included 30 patients each near the site of operation (Fig. 1). The control patients were
of whom required removal of a single impacted mandibular given no corticosteroid. Randomisation was by a table of ran-
third molar under local anaesthesia. dom numbers. The trial was not blinded, and patients were
Inclusion criteria included partially impacted mandibular aware of whether they had had dexamethasone or not.
third molars with Class II or III occlusions and Pell and Gre- As well as dexamethasone, all patients were given amoxi-
gory classification A, B, or C on the radiograph. Subjects cillin 500 mg every 8 h orally for 5 days, and tramadol 50 mg
were 18 years of age or older, and had no pericoronitis or orally as required as “rescue” analgesia. They were also given
infection at the time of operation. a chlorhexidine mouth rinse to be used twice daily starting
Exclusion criteria included a history of immunocompro- on the day after operation for 5 days.
mise; a history of allergy to the drug used; recent use of
any anti-inflammatory drugs or antibiotics; long-term use of Assessment and follow up
any drug; pregnancy or lactation; those who refused to take
part in the study; or those who used other drugs during the Measurements of facial swelling, trismus, and pain were
observation period. made preoperatively and on the first, third, and seventh post-
operative days by an independent examiner.
Operative technique Facial swelling on the operated side was evaluated by 2
facial measurements: tragus-midline and gonion-lateral can-
The same surgeon operated on all patients using a standard thus using a tape measure.21 The preoperative sum of the 2
technique. Anaesthesia was by a standard inferior alveolar values (mm) was taken as the baseline for that side. Trismus
nerve block and long buccal nerve block using a solution was measured as the difference in maximal mouth opening
of 2% lignoocaine hydrochloride and adrenaline 1:100 000. before and after operation. Postoperative pain was evaluated
Surgical access was by a standard triangular mucoperiosteal with a visual analogue scale (VAS), 100 mm long, that ranged
flap. Bone was then removed around the tooth with a round from 0 = “no pain” to 100 = “the worse possible pain” 6 h
bur on a straight handpiece under continuous irrigation with postoperatively and on the days of follow up. Patients were
dilute chlorhexidine solution. The crown or roots were sec- also instructed to report the number of rescue analgesic tablets
tioned when necessary. After complete extraction of the tooth taken. The number of tablets required was recorded until the
(or its components), the socket was inspected, irrigated copi- seventh postoperative day.
ously, and the flap was sutured back with 2 interrupted 4/0
silk sutures. A small gauze pack was then applied to the site Data analysis
and the usual postoperative instructions given to the patient.
The duration of operation (minutes from incision to the last The significance of differences between the groups was cal-
suture) was recorded. culated with the help of the Statistical Package for the Social
Sciences (SPSS version 12, SPSS Inc., USA). Descriptive
Postoperative treatment statistics included mean (SD), and the analysis of vari-
ance (ANOVA) or the chi square test, as appropriate, was
Patients were randomly divided into 3 groups of 10 patients. used to assess the significance of differences. Different vari-
The two treatment groups received dexamethasone 4 mg ables within groups were compared by repeated-measures
 O.W. Majid, W.K. Mahmood / British Journal of Oral and Maxillofacial Surgery 49 (2011) 647–652 649

Table 1
Characteristics of the patients in the study groups. Data are mean (SD) or number.
Variable Control group Intramuscular dexamethasone Submucosal dexamethasone Total p value
Age (years) 24.9 (3.3) 30.3 (8.6) 25 (4.7) 26.7 (6.3) 0.78
Sex
Male 4 7 5 16 0.60
Female 6 3 5 14
Smoking
Yes 1 2 0 3 0.52
No 9 8 10 27
BMI (kg/m2 ) 24.2 (2.4) 27 (3.1) 23.8 (3.3) 25 (3.2) 0.05
Position
A 5 3 3 11
B 5 5 7 17 0.52
C 0 2 0 2
Relation/ramus
CII 9 7 10 26 0.26
CIII 1 3 0 4
Duration of operation (min) 37 (8.8) 40.7 (12.5) 29.6 (8.3) 35.7 (10.8) 0.06

BMI = body mass index.

ANOVA, and the Bonferroni correction was used for post Measurements of trismus differed significantly between
hoc analyses. Probabilities of less than 0.05 were accepted as the submucosal dexamethasone group and the controls on day
significant. 1 (p = 0.04), but there were no other significant differences
among the groups (Table 2, Fig. 3).
The two dexamethasone groups differed significantly from
Results controls at all time intervals (p < 0.05), except for the intra-
muscular group on day 1 (Table 2, Fig. 4). The accumulated
Personal and clinical details of patients and duration of oper- number of rescue analgesic tablets taken at each interval also
ation are listed in Table 1. There were 16 men and 14 women, differed significantly between the dexamethasone and the
mean (SD) age 27 (6) years, range 20–48. There were no sig- control groups (p < 0.05) except for the intramuscular group
nificant differences among the groups. No cases of alveolar on day 1. No patient took pain killers after day 5.
osteitis or wound infection were reported at follow up. One
patient reported paraesthesia of the lip, which resolved by
the seventh postoperative day. No side effects of drugs were
mentioned or noted.
There was a significant increase in swelling on the first
(p < 0.001) and the third (p = 0.01) days, but not on the seventh
day (p = 0.08) compared with preoperatively in the control
group. However, there was no significant difference in the
magnitude of swelling in either dexamethasone group at
any interval, although both showed highly significant reduc-
tions in swelling compared with the control group (p < 0.001)
(Table 2, Fig. 2). Fig. 3. Profile differences in mean trismus measurements.

Fig. 2. Profile differences in mean swelling measurements. Fig. 4. Profile differences in mean pain perception.
650 O.W. Majid, W.K. Mahmood / British Journal of Oral and Maxillofacial Surgery 49 (2011) 647–652

Table 2
Mean (SD) measurements of swelling, pain, and trismus among the groups.
Variable Control group Intramuscular dexamethasone Submucosal dexamethasone p value
Swelling (mm)
Day 1 3.3 (0.82) 0.6 (0.75) 0.7 (0.6) <0.001
Day 3 2.4 (0.9) 0.3 (0.42) 0.5 (0.6) <0.001
Day 7 0.7 (0.41) 0.05 (0.15) 0.06 (0.2) <0.001
Pain (VAS)
Day 0 8.1 (1.3) 4.5 (2.5) 4 (2.9) 0.001
Day 1 6.3 (2.9) 3.6 (3.1) 2.8 (3.1) 0.04
Day 3 5.8 (3.1) 1.1 (2.1) 1.5 (2.4) 0.003
Day 7 3.6 (4.5) 0.2 (0.6) 0.2 (0.6) 0.005
Trismus (mm)
Day 1 22.4 (10.2) 14.5 (9.3) 10.8 (9.4) 0.037
Day 3 18.5 (11.7) 10.4 (8.8) 8.2 (8.8) 0.07
Day 7 12.8 (10.7) 5.1 (4.3) 5.4 (7.9) 0.07
Number of tablets 6.6 (3.7) 2.2 (2.1) 1.5 (1.4) <0.001

VAS = visual analogue scale.

Discussion be used when a steroid injection is prescribed in outpa-

tients. Intramuscular dosing studies have suggested that
Perioperative use of corticosteroids is a pharmacological this route can be effective if a single dose is given either
approach often used for reduction of oedema, trismus, and preoperatively or postoperatively.7 Different studies have
pain after removal of impacted mandibular third molars.7,16,17 used this route for third molar surgery and reported vari-
Numerous papers have supported their systemic use in third able results2,5 ; the effect may be dose-dependent. Some
molar surgery.2,4–11 Recently, Markiewicz et al.,18 in a authors suggested using dexamethasone 8–12 mg for the best
meta-analysis, concluded that giving corticosteroids peri- results.16
operatively was of mild to moderate value in reducing In our study intramuscular dexamethasone resulted in
postoperative inflammatory signs and symptoms. Specifi- significant reduction in swelling on postoperative days 1
cally, patients given corticosteroids had significantly less and 3 and significant reduction in pain scores, but had
postoperative swelling and trismus than controls, both early no significant effect on trismus compared with controls.
(after 1–3 days) and late (after 4–7 days). In addition, These results are in agreement with those of previous
those who took corticosteroids reported less pain early studies.2,5,21,24
but not late postoperatively than control groups. However,
the effect on postoperative morbidity, and the duration of Submucosal dexamethasone
the effect of the corticosteroids, varied, mainly as a result
of lack of consensus about the optimal route, dose, tim- The submucosal injection of dexamethasone has been
ing, and duration of treatment in addition to differences in reported to have a significant effect on oedema in two
methods used to evaluate clinical variables. The submu- previous studies,12,14 both of which reported a signifi-
cosal route, however, has been reported on only isolated cant reduction in oedema in the immediate postoperative
occasions and was not mentioned even in most recent period compared with controls, but only a limited effect
reviews.16,18–20 on trismus and pain. We found that submucosal dexam-
The corticosteroid selected should have few mineralocor- ethasone was associated with a significant reduction in
ticoid effects and good biological activity. Dexamethasone swelling on days 1 and 3 postoperatively compared with
meets these requirements, as it has no mineralocorticoid controls, which agrees with the previous studies. These
activity, the half-life is roughly 36–72 h, and the drug is 25 results add more strength to the concept that dexamethasone
times more potent than hydrocortisone. It also seems to have injected locally near the site of operation in a subtherapeu-
the least depressing effect on leucocyte chemotaxis. There tic dose (4 mg) is a valuable way to reduce oedema in these
have been many studies that have evaluated the effective- patients.
ness of dexamethasone in third molar surgery using different An interesting finding was the significant reduction of tris-
routes with variable results.2,5,7,8,12,14,21–23 mus on day 1, which may have been the result of the higher
concentration of dexamethasone achieved immediately at the
Intramuscular dexamethasone site of injury. Further research, however, is needed to confirm
these results.
Few studies have objectively evaluated the effect of dex- Unlike previous studies, our patients reported signifi-
amethasone as an intramuscular injection in third molar cantly less pain at all evaluation times in the submucosal
surgery, although this route is the one most likely to group compared with controls. Graziani et al.,12 however,
 O.W. Majid, W.K. Mahmood / British Journal of Oral and Maxillofacial Surgery 49 (2011) 647–652 651

did not report which analgesic was prescribed as rescue 2. Messer E, Keller J. The use of intraoral dexamethasone after extrac-
medication postoperatively, and pain was assessed only sub- tion of mandibular third molars. Oral Surg Oral Med Oral Pathol
jectively (on a VAS) without the number of analgesic tablets 1975;40:594–8.
3. Milles M, Desjardins P. Reduction of postoperative facial swelling by
taken. Grossi et al.,14 in the other study, gave an injection low-dose methylprednisolone: an experimental study. J Oral Maxillofac
of dexamethasone just before the operation and after the Surg 1993;51:987–91.
anaesthetic had been given. The raising of the flap and manip- 4. Skjelbred P, Lokken P. Post-operative pain and inflammatory reaction
ulation of tissue during the operation may have affected the reduced by injection of a corticosteroid. A controlled trial in bilateral
concentration of drug injected and impeded its absorption. oral surgery. Eur J Clin Pharmacol 1982;21:391–6.
5. Pedersen A. Decadronphosphate in the relief of complaints after third
Knowing that the effect of dexamethasone on pain is dose- molar surgery. A double-blind, controlled trial with bilateral oral surgery.
dependent,23 we assume that a higher dose is required when Int J Oral Surg 1985;14:235–40.
the drug is given preoperatively to achieve clinically effective 6. Beirne OR, Hollander B. The effect of methylprednisolone on pain,
analgesia. trismus, and swelling after removal of third molars. Oral Surg Oral Med
Oral Pathol 1986;61:134–8.
7. Montgomery MT, Hogg JP, Roberts DL, Redding S. The use of glu-
Submucosal compared with intramuscular cocorticosteroids to lessen the inflammatory sequelae following third
dexamethasone molar surgery. J Oral Maxillofac Surg 1990;48:179–87.
8. Neupert III EA, Lee JW, Philput CB, Gordon JR. Evaluation of dexam-
ethasone for reduction of postsurgical sequelae of third molar removal.
To the best of our knowledge this is the first study in which
J Oral Maxillofac Surg 1992;50:1177–82.
the effects of local and systemic steroids have been com- 9. Esen E, Tasar F, Akhan O. Determination of the anti-inflammatory
pared in third molar surgery. Both dexamethasone groups effects of methylprednisolone on the sequelae of third molar surgery.
were associated with a significant reduction in the amounts J Oral Maxillofac Surg 1999;57:1201–6.
of swelling and pain, and submucosal dexamethasone had 10. Ustün Y, Erdogan Ö, Esen E, Karsli ED. Comparison of the effects of 2
doses of methylprednisolone on pain, swelling, and trismus after third
a significant effect on trismus, but the effects in the two
molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
groups were comparable for all variables. Although there is 2003;96:535–9.
wide consensus about their effect on swelling, the role of 11. Tiwana PS, Foy SP, Shugars DA, Marciani RD, Conrad SM, Phillips C,
corticosteroids in preventing postoperative pain is controver- et al. The impact of intravenous corticosteroids with third molar surgery
sial. Many authors13,21 have recorded a significant reduction in patients at high risk for delayed health-related quality of life and
clinical recovery. J Oral Maxillofac Surg 2005;63:55–62.
in pain 4–6 h postoperatively but not later; others.9,15 how-
12. Graziani F, D’Aiuto F, Arduino PG, Tonelli M, Gabriele M. Perioper-
ever, have reported reduction in pain 6 h after extraction ative dexamethasone reduces post-surgical sequelae of wisdom tooth
and over the subsequent 3 days. It has also been reported removal. A split-mouth randomized double-masked clinical trial. Int J
that steroids can be related to a reduction in the number of Oral Maxillofac Surg 2006;35:241–6.
analgesic tablets used after extractions,9,17 which we also 13. Mico-Llorens JM, Satorres-Nieto M, Gargallo-Albiol A, Arnabat-
Domınguez J, Berini-Aytes L, Gay-Escoda C. Efficacy of methylpred-
found. nisolone in controlling complications after impacted lower third molar
Overall, the comparable results obtained show that surgical extraction. Eur J Clin Pharmacol 2006;62:693–8.
submucosal dexamethasone is an effective alternative to dex- 14. Grossi GB, Maiorana C, Garramone RA, Borgonovo A, Beretta M, Far-
amethasone given systemically. The expertise of the surgeon, ronato D, et al. Effect of submucosal injection of dexamethasone on
the discomfort caused to the patient, and the need for spe- postoperative discomfort after third molar surgery: a prospective study.
J Oral Maxillofac Surg 2007;65:2218–26.
cific tools to give the drug are factors that may limit the use 15. Vegas-Bustamante E, Mico-Llorens J, Gargallo-Albiol J, Satorres-Nieto
of the intramuscular route.9 In addition, the rate of absorp- M, Berini-Aytes L, Gay-Escoda C. Efficacy of methylprednisolone
tion is highly dependent on the blood flow to the site.19 injected into the masseter muscle following the surgical extraction of
Submucosal dexamethasone, on the other hand, is quite impacted lower third molars. Int J Oral Maxillofac Surg 2008;37:260–3.
simple, less invasive, painless, convenient for the surgeon 16. Alexander RE, Throndson RR. A review of perioperative corticosteroid
use in dentoalveolar surgery. Oral Surg Oral Med Oral Pathol Oral
and the patient, and offers a low-cost solution for the typ- Radiol Endod 2000;90:406–15.
ical discomfort associated with the extraction of impacted 17. Gersema L, Baker K. Use of corticosteroids in oral surgery. J Oral
lower third molars. Postoperative injection offers the advan- Maxillofac Surg 1992;50:270–7.
tage of concentrating the drug near the surgical area with 18. Markiewicz MR, Brady MF, Ding EL, Dodson TB. Corticosteroids
less systemic absorption and no further manipulation of the reduce postoperative morbidity after third molar surgery: a systematic
review and meta-analysis. J Oral Maxillofac Surg 2008;66:1881–94.
tissues. This timing also allows the surgeon to assess the
19. Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of
need for injected steroid accurately, according to postop- corticosteroids and nonsteroidal anti-inflammatory medication for the
eratively recorded surgical difficulty and duration of the management of pain and inflammation after third molar surgery: a review
intervention. of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2009;107:630–40.
20. Apiliogullari S, Yıldırım G, Ataoglu H. The supraperiosteal route of dex-
amethasone should be considered for dental surgery (letter to the editor).
References Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;108:165–6.
21. Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain
1. Shepherd JP, Brickley M. Surgical removal of third molars. BMJ and swelling following extraction of third molar teeth. Anaesthesia
1994;309:620–1. 1993;48:961–4.
 652 O.W. Majid, W.K. Mahmood / British Journal of Oral and Maxillofacial Surgery 49 (2011) 647–652

22. Schmelzeisen R, Frolich JC. Prevention of postoperative swelling and in a clinical model of acute inflammation. J Oral Maxillofac Surg
pain by dexamethasone after operative removal of impacted third molar 2003;61:997–1003.
teeth. Eur J Clin Pharmacol 1993;44:275–7. 24. Moore PA, Brar P, Smiga ER, Costello BJ. Preemptive rofecoxib and
23. Dionne RA, Gordon SM, Rowan J, Kent A, Brahim JS. Dexam- dexamethasone for prevention of pain and trismus following third molar
ethasone suppresses peripheral prostanoid levels without analgesia surgery. Oral Surg Oral Med Oral Pathol 2005;99:E1–7.

View publication stats