Abstract
The aim of this study was to compare the effect of intramuscular (IM) injection and consumption of 8 mg dexamethasone in patients after lower third molar (LTM) surgery. 20 healthy Thai patients, average age 20 years, with bilateral LTM removal were recruited for this study, a double blinded, paired sample clinical trial. The washout period was 1 month after the first operation. Clinical assessment of facial swelling, pain and maximum mouth opening were measured before and after operation for 7 days. No significant difference was found in facial swelling between IM injection and consumption of 8 mg dexamethasone after LTM surgery (paired t test P > 0.05). The visual analogue scale scores for pain assessment showed no significant difference between IM injection and consumption of dexamethasone (paired t test P > 0.05). The results conclude that IM injection or consumption of dexamethasone after LTM surgery can be used to control facial swelling, pain and trismus.
In most patients, the postoperative complications from lower third molar (LTM) surgery are severe pain and facial swelling; some patients also have trismus. Many previous studies of LTM surgery have focused on reducing swelling, pain and trismus, for example using small tube drainage, and non-steroidal anti-inflammatory drugs (NSAIDs) including steroids .
Dexamethasone is a synthetic corticosteroid with much greater anti-inflammatory effect. The potency of dexamethasone is about 20–30 times that of natural corticosteroid . B odnar studied the use of steroids in reducing postsurgical pain and facial swelling. A lexander and T hrondson reported many regimens using dexamethasone based on anecdotal information from previous articles.
Dexamethasone injection
P ederson used 4 mg dexamethasone (Decadron Phosphate ® ) injected into the masseter muscle before starting LTM surgery. M arkovic and T odorovic studied 4 mg intramuscular (IM) injection of the internal pterygoid and deltoid muscles as well as consumption 6 h postoperatively. G raziani et al. also studied postoperative pain and swelling, using 10 mg submucosal dexamethasone, 4 mg and 10 mg endo-alveolar powder, all given perioperatively. G rossi et al. studied the effect of submucosal administration of dexamethasone on post-operation discomfort after mandibular third molar surgery. P oswillo reported the studies of Hooley and Kohl, Greenfield and Caraso that used dexamethasone IM injection at the time of LTM surgery. T iwana et al. studied the use of intravenous (IV) corticosteroid before LTM surgery for health-related quality of life. B amgbose et al. studied 8 mg and 4 mg IV dexamethasone in LTM surgery.
Dexamethasone consumption
S chmelzeisen and F rölich reported decreased swelling on the first postoperative day with the use of a 6 mg dexamethasone tablet, given both pre- and postoperatively. M arkovic and T odorovic studied dexamethasone consumption 6 h postoperatively. E lHag et al. used 10 mg dexamethasone given pre- and postoperatively for LTM surgery as well as ultrasound therapy. Many previous studies have used many regimens and modes of administration of dexamethasone in LTM surgery to decrease postoperative facial swelling, severe pain and trismus. F ilho et al. studied 4 mg and 8 mg of dexamethasone injected before LTM surgery and showed that 8 mg was more effective than 4 mg.
The present study aimed to compare the effect of 8 mg dexamethasone IM (deltoid muscle) injection immediately postoperation and 8 mg dexamethasone consumption postoperation on the day of LTM surgery.
Dexamethasone consumption
S chmelzeisen and F rölich reported decreased swelling on the first postoperative day with the use of a 6 mg dexamethasone tablet, given both pre- and postoperatively. M arkovic and T odorovic studied dexamethasone consumption 6 h postoperatively. E lHag et al. used 10 mg dexamethasone given pre- and postoperatively for LTM surgery as well as ultrasound therapy. Many previous studies have used many regimens and modes of administration of dexamethasone in LTM surgery to decrease postoperative facial swelling, severe pain and trismus. F ilho et al. studied 4 mg and 8 mg of dexamethasone injected before LTM surgery and showed that 8 mg was more effective than 4 mg.
The present study aimed to compare the effect of 8 mg dexamethasone IM (deltoid muscle) injection immediately postoperation and 8 mg dexamethasone consumption postoperation on the day of LTM surgery.
Materials and methods
This study included 20 healthy Thai patients (3 males, 17 females), average age 20 years (range 15–23 years), with bilateral LTM in similar positions and the same degree of surgical difficulty ( Table 1 ), for which surgical removal (consisting of bone cut and tooth division) had been indicated. They had no history of allergy to dexamethasone, amoxicillin, or acetaminophen, and had no use of other medicines 1 month before and during the study period. A double blinded, paired sample clinical trial was used for this study.
| Type of LTM | Number |
|---|---|
| Horizontal LTM impaction | 10 |
| Distoangular LTM impaction | 3 |
| Mesioangular LTM impaction | 7 |
The patients voluntarily participated in the study after giving informed consent. Written consent was also obtained from the patients for publication of the study findings. The patients signed consent forms in the presence of a witness for all examinations and treatments performed. This study was one part of a dexamethasone study that the Mahidol University Institutional Review Board approved and accepted as a clinical study with Protocol No. MU-IRB 2010/281.0810.
This study used 8 mg (2 ml) dexamethasone (dexamethasone sodium phosphate) injected IM (deltoid muscle) immediately postoperatively with placebo tablet (total 16 tablets, 4 times/day) consumption and 2 ml normal saline solution and dexamethasone consumption, total 8 mg, in 1 day (4 tablets of 0.5 mg dexamethasone four times) used in another site. The washout period for the second operation was 1 month after the first operation. Both sides of the patients’ LTMs were surgically removed by the same surgeon. On postoperative days, 1, 3 and 7, facial swelling, pain and maximum mouth opening were recorded and compared amongst groups.
Before the LTM surgery was conducted, 1 g amoxicillin was consumed by the patients 1 h before surgery and measured on two lines along the length of the face from the reference points, lateral corner of the eye to angle of the mandible and tragus of the ear to corner of the mouth as indicated in Fig. 1 . The pain level was measured by visual analogue scale (VAS) and the maximum interincisal distance for mouth opening was also measured.
All the LTM surgeries were conducted under the standard inferior alveolar nerve and buccal nerve block, using the same standard surgical technique. The surgery began by opening a flap and the buccal bone around the LTM was removed. The LTM was divided into small pieces, followed by primary wound closure by interrupted suture . The same postoperative care and continual medicine, 20 capsules of 500 mg amoxicillin, were administered orally one capsule at a time, four times a day and 20 tablets of 500 mg acetaminophen were administered orally, at two tablets, every 4–6 h as needed, but not exceeding 4 g per day, given to all patients. The patients were told to record the number of analgesics consumed on each day for 7 days postoperatively.
On postoperative days 1, 3 and 7, the length of the patients’ face, the VAS pain level, and the maximum interincisal distance was measured. The patients’ data were statistically analysed, using Statistical Package for the Social Sciences (SPSS), by means of analytical statistic and the paired t test. The level of significance used in the statistical decisions was P < 0.05.
Results
The operation times for LTM surgery in the dexamethasone IM injection group and the consumption group were not significantly different ( Table 2 ). The 8 mg dexamethasone IM injection and 8 mg dexamethasone consumption groups showed no significant differences in postoperative facial swelling after LTM surgery on days 1, 3 and 7 ( Table 3 ). Both groups had postoperative pain 7 days after LTM surgery, evaluated using the VAS pain rating scale ( Table 4 ), and the total amount of acetaminophen consumption ( Fig. 2 ) was not significantly different.
| Time (min) | IM group | Consumption group | P value |
|---|---|---|---|
| Range | 7–34 | 5–36 | |
| Mean | 20.9 | 20.3 | 0.77 |
| SD | 7.37 | 7.66 |
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