In by twin mix, intravenous, and intra muscular groups.

In 1965,
Linenberg4 worked with one of the new synthetic adrenocortical steroids,
dexamethasone, to limit edema and reduce trismus and pain after oral surgical
procedures, and due to his studies, the use of steroids gained popularity in
oral surgical procedures.

Dexamethasone is
a effective synthetic glucocorticoid class
of steroid drug
that possess anti-inflammatory and immunosuppressant qualities.
It is 25 times more potent than cortisol in its glucocorticoid action, with
minimal mineralocorticoid effect, and a half life of 36-54 hours, making it preferred
drug for a single shot therapy in dealing with surgically induced inflammation.3

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This study
compared post operative sequel of intra-space injection of dexamethasone in
pterigomandibular space as Twin mix and other routes of administering steroids
via intraoral submucosal, intramuscular, intravenous and per-oral tablets. The
regime for corticosteroid administration (4 mg, preoperatively) used in this
study was based on the inferences of studies by Tiwana et al.5 and
Grossi et al6. Tiwana et al. found that preoperative administration
of corticosteroids provided a better clinical outcome, whereas Grossi et al.
observed that dose regimes of 4 or 8 mg had no statistical significant
differences on the clinical outcome.

All
the dexamethasone groups showed lesser swelling than the control group (Table 1a).

The intraoral
submucosal group showed least edema, followed by twin mix, intravenous, and
intra muscular groups. Among the dexamethasone groups, the Per Oral Group
showed maximum increase in edema, and its difference with the Control Group was
not found to be statistically significant (p=0.499).

This is in
agreement with preceding studies, which highlight that when dexamethasone is
applied submucosally, its anti-edema effect increases2,7. F.
Graziani stresses that the genesis of facial edema is dependent on trauma to
tissues during the surgery. Direct administration of the steroid in the
traumatized tissues will help combat the inflammation- related events8.
Differences in increase in facial dimension on day 3 continued to be
statistically significant (p=0.002) (Table 1b) with the Intraoral
Submucosal Group showing least edema followed by Twin Mix & Intravenous
groups. Although the Intramuscular & PerOral Groups showed better mean values
than the Control Group, the difference was not found to be statistically
significant. On the 7th post operative day the differences in
increase in facial dimension was not found to be statistically significant
(p=0.107) (Table
1b).

At Day 1,
decrease in mouth opening in our study population ranged from 6 to 42 mm.
Maximum mean decrease in mouth opening was observed in Intramuscular Group
(27.10±7.28 mm) while minimum decrease in mouth opening was observed in
Intraoral Submucosal Group (18.15±6.87 mm) followed by Twin Mix, Per Oral,
Intravenous and lastly Control Group(Table 2a). On comparing between
the Groups in decrease in mouth opening, differences were found to be
statistically insignificant (p=0.175). On the 3rd (p=0.261) &
the 7th (p=0.508) post operative day (Table 2b),
the between the Groups comparison continued to remain statistically
insignificant. These findings seem to confirm other previously reported data,
since steroids do not exert any direct effects on muscle contraction.
Statistically non significant benefits could be secondary due to decreased
degree of local inflammation8-12. The relationship between trismus
and pain has been noted before13-15. Hence it might be anticipated
that mouth opening after surgery of impacted mandibular third molars is painful
and therefore limited from its full extent. This hypothesis has been established
by an electromyographic study by B. E. Greenfield, & J.R. Moore where they
inferred that restricted mandibular movements post surgery reflects a voluntary
act to avoid pain16.

Pain was noted
on VAS scale. In the present study pain score ranged from 0 to 8 with a mean
score of 3.67±1.77. Maximum mean pain score was observed in Control Group
(5.10±2.08) while minimum mean pain score was in Twin Mix Group (2.70±1.95).

When comparing
group differences in Pain score (Table 3a) at day 1, significant
result (p=0.046) was obtained, with Twin Mix & Intra oral Submucosal routes
clearly showing most favorable outcomes, in stark contrast to Per Oral Tablet
route & Control Group, which showed worst outcomes. Although the
Intravenous & Intramuscular groups showed lesser mean pain scores than Per
Oral Tablet & Control Group the difference was statistically insignificant.
Acute postoperative pain following impaction surgry is mainly a consequence of
inflammation due to tissue injury17. The action of corticosteroids
in preventing postsurgical pain is divisive. According to Beirne &
Hollander, dexamethasone in particular seems to reduce pain after surgery12.
Numerous studies demonstrate that pain reduces with dexamethasone, but an apparent
pathway for this effect has not been established. Boworn Klongnoi et al suggest
that edema makes the tissue tense and leads to tension pain that is reduced
when dexamethasone decreases the edema10. Differences in VAS scores
continued to remain statistically significant (p=0.013) even on the 3rd
post operative day, showing better pain reduction in the Intraoral Submucosal
Group & Twin Mix Group when compared to Control & Per Oral Tablet
Group. When we correlate this finding with the results Beirne & Hollander12
obtained with methlyprednisolone we can clearly see the benefit of the long
half life of dexamethasone in controlling pain even on the 3rd post
operative day. On the 7th post operative day only Intraoral
Submucosal Group showed highly significant difference with the Control group
(p=0.007) (Table
3b).

A further
unwanted consequence of the surgical removal of mandibular third molars is the
occurrence of paresthesia of the inferior alveolar or lingual nerves.

Since
dexamethasone has been shown to reduce post-operative oedema, it was decided to
investigate the specific effect of dexamethasone on neurapraxia following
removal of mandibular third molars as it was felt that this effect may reduce
nerve damage caused by pressure or oedema.

However,
unfortunately (for the study purpose of course!) none of the patients reported
any sensory deficit, & so the role dexamethasone can have on post surgical
paresthesia following removal of impacted mandibular third molars could not be
assessed.

 

Steroid
administration along with surgical removal of wisdom teeth has apparently never
led to specific general complaints4,18. In the present study, there
was no increased frequency of local complications. Specifically, short-time
steroid administration to healthy individuals does not increase the risk of
delayed healing and local infection. Unfortunately, patients’ preference was
not recorded in the present investigation. In evaluation of the overall effect
of the treatment, this must be of major importance.

The
ultimate goal in the treatment of patients should be total comfort with lack of
complications, and this is an end for which we all should strive. Our surgical
techniques should be based on this desire, and as we treat greater numbers of
patients, our clinical judgment of what is required for patients should become
increasingly acute. With knowledge of our past experiences in the treatment of
many patients, we should reasonably predict that “with this procedure, in my
hands, on this patient, under these circumstances, this result can be
expected.”

In
the current study, use of Intraoral Submucosal Dexamethasone clearly showed
most desirable outcomes. Grossi G.B. et al. too reciprocate similar advantages
of the Submucosal route, and reason that, injection of even low-dose
dexamethasone in the surgical site achieves a higher effective drug
concentration at the site of injury without loss due to distribution to other
compartments or the onset of elimination6. Al-Khateeb et al.19
state that the submucosal infiltration technique does not require clinician’s
expertise or additional armamentarium as it is a local infiltration of the
steroid submucosally around the site of surgery.

Patients who seek third molar surgery not only expect the surgeon to
explain the risks and benefits of the planned procedure, but also the details
of recovery from the surgery. Lopes et al20 reported the results of
a study that included a questionnaire sent out 12 months after removal of
wisdom teeth. Twenty-two percent of respondents considered that they still had
a persistent problem! Meticulous surgical techniques will minimize the sequelae
of inflammation but cannot prevent them altogether.

The pre operative use of submucosal dexamethasone most effectively
reduced the post operative, swelling and trismus showing statistically
significant results. Pain control was found to be very slightly better in the
Twin Mix Group than the Submucosal Group. Also, the sub mucosal dexamethasone
posses many advantages over the other routes of administration. From our study,
we can conclude that the single pre operative dose of submucosal dexamethasone
effectively improves the post operative quality of life in the surgical
management of impacted mandibular molars. A larger
series is indicated to validate these findings & also obtain more
statistically significant results.

Funding: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.