Sub-mucosal Dexamethasone for Post-operative Pain and Oedema Control in Lower Third Molar Surgery.

Background: Surgical excision of the problematic mandibular third molars causes substantial tissue damage and an inflammatory response. Discomfort and edema are common postoperative signs and symptoms caused by the latter. To find out whether dexamethasone may help with the edema and pain that come along with the surgical removal of impacted mandibular third molars, researchers have performed clinical studies.
Methods: Twenty individuals with bilaterally affected mandibular third molars who were scheduled for extraction participated in a prospective trial. At two separate sessions, teeth were raised and cut after buccal ostectomy. Since the surgical operation on the left foot, both patients were administered a mixture of 4 mg dexamethasone submucosal injection and antibiotics for 3 days. On the 1st, 3rd, and 7th postoperative days, edema and pain were assessed.
Results: At the 1st, 3rd, and 7th postoperative days, there was a clinically meaningful decrease in the level of edema and discomfort in both arms. Conclusions: The current report offers empirical proof that administering a 4 mg dexamethasone submucosal injection during surgery greatly reduced post-surgical edema and discomfort. Copyright:

INTRODUCTION

Third molar impaction is a chronic disorder that often necessitates tooth extraction. Impaction is characterized as the inability of a tooth to erupt at its proper location in the dental arch during its usual growth time. Ninety percent of the general population has impacted mandibular third molars, with 33% of individuals possessing at least one impacted mandibular molar.[1]

Pericoronitis, which may contribute to orofacial lesions, cysts, or neoplasms, as well as caries, periodontitis, germination defects, root resorption of neighboring teeth, and orthodontic and prosthetic treatment issues, are all linked to impacted mandibular third molar teeth.[2]

Many of these problems get resolved by having the offending tooth extracted. The most popular surgical operation performed is the prophylactic or curative removal of the impacted third molar teeth. This treatment is often followed by edema and discomfort, all of which are physiological activities affecting the inflammatory reaction that, if exaggerated, may disrupt the patient's comfort and social life.[2]

The anti-inflammatory characteristics of corticosteroids have been utilized to minimize the inflammatory consequences following surgical excision of the third molar.[3] Various doses and methods of administration are available. Anti-inflammatory glucocorticoids may lower the number of lymphocytes in the blood, prevent capillary dilation or fibroblast growth, and alter the generation of prostaglandin or leukotrienes at any stage of inflammation. Corticosteroids are powerful anti-inflammatory agents that work by inhibiting phospholipase A2. Prostaglandin and leukotriene production by immune cells such as neutrophils is reduced when this protein is reduced, which means that postoperative signs and symptoms are less likely to be seen.[3]

Dexamethasone, methylprednisolone hydrocortisone, and betamethasone[4] are the most commonly used corticosteroids for suppressing postoperative edema and discomfort. Delay in recovery and a rise in the patient's propensity of infection are two of the side effects that have been observed.[5] The most popular corticosteroid used to relieve pain and edema during oral surgical operations is dexamethasone.[6]

The submucosal path has the benefit of low dose, localized administration, and short-term exposure, both of which result in reduced side effects such as immunosuppression.[7]

The goal of this study is to examine the effectiveness of submucosal dexamethasone injections to treat pain and edema after third molar surgery in controlled and uncontrolled studies.

MATERIALS AND METHODS

Data came from the following sources:

The research was carried out at the Oral and Maxillofacial Surgery Department at the University of California, San Francisco.

Criteria for acceptance:

Surgeons needing to remove lower third molars from patients between the ages of 18 and 40

Patients who are cooperative, inspired, and hygiene-aware

Criteria for exclusion:

Patients suffering from uncontrollable systemic disorders

Patients that refuse to participate in the research

Chronic smokers

Data were gathered using the following method

After receiving informed consent, 20 patients with a lower third molar that required surgical removal were chosen for this prospective clinical trial. Using a measuring pad, preoperative facial measurements were taken from the tragus-midline to the gonion-lateral canthus [Tables 1 and 2]. Preoperative images were made in four separate views: frontal, lateral, bird's eye, and worm's eye. The procedure was carried out under local anesthesia. The impacted lower third molar was surgically cut, and the main closure was completed with 3-0 mersilk. Following surgery, a submucosal injection of 4 mg/1 mL dexamethasone sodium phosphate was administered.

Table 1

Comparison of the mean (tragus midline) between test and control groups test applied-independent sample t test

Time interval	Dexamethasone		Control		Mean difference	T	P
	Mean	SD	Mean	SD
Pre-op	13.1	0.11	13.8	0.18	0	0	1
1st day	15.1	0.15	15.1	0.21	−0.21	3.9	0.00*
3rd day	14.7	0.19	15.3	0.19	−0.29	3.2	0.00*
7th day	14.9	0.33	14.5	0.19	−0.44	1.9	0.02*

Table 2

Comparison of the mean (lateral canthus - gonion) between test and control groups; test applied- independent sample t test

Time interval	Dexamethasone		Control		Mean difference	T	P
	Mean	SD	Mean	SD
Pre op	10.11	0.12	11.11	0.33	0	0	1
1st day	11.23	0.30	11.09	0.26	−0.23	1.1	0.01*
3rd day	12.11	0.45	11.26	0.44	−0.45	1.7	0.00*
7th day	10.21	0.44	11.17	0.56	−0.55	2.1	0.00*

Edema and pain were assessed three times after surgery: on the first, third, and seventh days. To compare the postoperative results to the preoperative ones, a measuring tape was used to measure the patient's face from the tragus to the midline and the gonion to the lateral canthus. Postoperative imaging was captured in four separate views: dorsal, lateral, bird's eye, and worm's eye.

Evaluation criteria include:

Pain (0–10) was assessed using a visual analog scale on the first, third, and seventh postoperative days.

Edema ranking based on facial measurements Using a measuring pad, postoperative facial measurements were taken from the tragus-midline to the gonion-lateral canthus and contrasted to preoperative facial measurements.

Using a stopwatch, the operating period was estimated from the beginning to the end of the operation.

RESULTS

The drug was well received by all 20 patients, with no significant problems or side effects. The wounds healed without a hitch. After third molar extraction, pain and edema were compared with and without dexamethasone sodium phosphate.

EDEMA

There was a statistically significant difference in postoperative edema on days 1, 3, and 7, between the control and test groups, with the control group showing more severe edema at day 1, and the test group showing milder edema at day 3, and no swelling remaining at day 7 in the test group.

Pain intensity scores

Third molar extraction did not significantly reduce mean pain intensity ratings on right or left sides after postoperative hours.

DISCUSSION

Pain and edema are the most frequent postoperative sequelae to surgical removal of impacted teeth, all of which are due to the local inflammatory response. The inflammation induced by tissue damage is the primary cause of acute postoperative pain after third molar extraction.[8]

Edema after third molar surgery is caused by extravasation of fluid by traumatized tissues as a consequence of the disruption or obstruction of lymph arteries, culminating in the termination of lymph drainage, which accumulates in the tissues.[9]

Adjunctive use of corticosteroids to decrease tissue mediators of inflammation and reduce fluid transudation and edema is common in surgical procedures.[10]

Long-acting steroids outperform short-acting steroids, and submucosal steroid administration has comparable consequences as intravenous and intramuscular routes.[7] The intramuscular path is a straightforward method of prescribing corticosteroids to alleviate intensified inflammatory responses. The procedure is painless as the injection location is close to an already anesthetized region. Local availability is provided by both the IM and SM routes; however, absorption is reliant on the availability of blood supply in the administration area and Oral steroids can trigger stomach problems; thus, it is better to take them with meals. In certain patients, steroids may induce depression or psychosis, but this result is unpredictable.[11]

Because of its higher efficacy, lower sodium retention potential, and longer half-life, dexamethasone was selected. This research found that prophylactic dexamethasone injection via the intraoral submucosal route reduces edema and pain in a statistically relevant way. The submucosal method, on the contrary, is a straightforward, painless, noninvasive, and cost-efficient procedure. There are no studies in the literature regarding the risks associated with a single dose of corticosteroid.[7]

The key goal of this research was to see how effective dexamethasone was at reducing edema and pain after surgically removing impacted mandibular third molars. Postoperative edema has been measured using a variety of methods.

Dexamethasone works to suppress edema by hydrolyzing bradykinin and acting as an antihistamine and anti-inflammatory. When examining preoperative and postoperative edema measurements in the control group, preoperative and postoperative measurements revealed a significant reduction in edema on both sides in the postoperative span. On both ends, the most edema was found postoperatively. At the 1st, 3rd, and 7th days after surgery, there was no statistically important difference in mean edema between the left and right sides (P > 0.05). However, in the dexamethasone group, there was a substantial decrease in post-operative edema following third molar extraction.

Dexamethasone works by preventing the release of pain-inducing amines, including bradykinin, from inflamed tissues. A considerable decrease in mean pain intensity ratings on both the right and left sides was seen after third molar extraction postoperatively despite no significant reduction in mean pain intensity scores on the right and left sides. In the dexamethasone community, pain relief was statistically important.

CONCLUSION

Treatment of postoperative problems after surgical extraction of damaged teeth plays a critical role in patient care and treatment of the patient. Pain is felt as a result of surgical damage to the tissues. It has a powerful anti-inflammatory impact by suppressing cell membrane formation of arachidonic acid as well as the generation of leukotrienes, prostaglandins, and thromboxans. Patients in the steroid community had a greater prog result and a higher standard of life than those in the non-steroid group in our research. Clinically, edema was reduced on the dexamethasone side than on the non-dexamethasone side. As a result, the current report offers direct empirical data that, while dexamethasone did not demonstrate a statistically meaningful reduction in the incidence of post-surgical edema, it did offer clinically relevant pain relief. As a result, this report recommends using a submucosal dexamethasone injection for wisdom teeth extraction to improve patient safety and quality of life.

Data availability statement

All the data is collected from the simulation reports of the software and tools used by the authors. The authors are working on implementing the same using real-world data with appropriate permissions.

Compliance with ethical standards

Ethical approval and human participation

No ethics approval is required.

Ethical committee clearance was taken from the institution.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Pain Intensity	4 h (%)	8 h (%)	24 h (%)
No pain	0	0	0
Mild annoying pain	0	0	0
Nagging, uncomfortable, troublesome pain	0	0	50%
Distressing miserable pain	27%	70%	50%
Intense, dreadful, horrible pain	73%	30%	0
Worst possible, unbearable, excruciating pain	0	0	0

Pain Intensity	4 h (%)	8 h (%)	24 h (%)
No pain	0	0	0
Mild annoying pain	87%	89%	100%
Nagging, uncomfortable, troublesome pain	13%	11%	0
Distressing miserable pain	0	0	0
Intense, dreadful, horrible pain	0	0	0
Worst possible, unbearable, excruciating pain	0	0	0