Role of Steroids in Reduction of Morbidity Following Mandibular Wisdom Tooth Surgery

 

SADDIQUE ASLAM, ASGHAR KAMAL*, MUHAMMAD SAJID**, AKHTAR MUNEER***, MUHAMMAD FAROOQ****

*Associate Professor, Medicine, KIMS, Kohat

**Assistant Professor, Pharmacology Deptt. KIMS, Kohat

***Assistant Professor, Pathology deptt. KIMS, Kohat

****Emergency Pathology Lab, SIMS/SHL, Lahore

Correspondence to Dr Saddique Aslam khattak, Assistant Professor, KMU institute of medical sciences, Kohat.Email:drsaddique@hotmail.com

 

ABSTRACT

 

Aim: To evaluate the preoperative therapeutic effect of oral (10mg prednisolone that is 2 tablets of deltacotril) on post operative complications like edema, limited mouth opening and pain following wisdom tooth surgery.

Study design: This was a randomized control trial study.

Setting: was conducted at the private clinic of the author and dental section of DHQ Hospital Kohat, Khyber Pukhtoonkhwa, Pakistan.

Study period: from January 2011 to august 2011.

Material & methods Eighty patients with bilateral mandibular wisdom teeth impaction were included in this study.  One  side of the  patient  last  mandibular molar  either  right or left, was allocated randomly as control  and  the other  side  as study group. Study group received 10mg prednisolone that is 2 tablets of deltacotril one hour before surgical extraction. Patients with contraindication to the use of steroids were excluded from this study.  Facial edema and maximal inter incisal distance were measured by an independent examiner at baseline (preoperatively), and at 3rd, and 6th postoperative days. Pain was measured by counting the number of rescue analgesic tablets taken, and from the patients’ response to a visual analogue scale.

Results: The steroid group showed significant reduction in edema (p=0.6862) and pain (p=0.1587) compared with the control group at all intervals. 10mg prednisolone that is 2 tablets of deltacotril resulted in significantly less limited mouth opening  than  controls on day3 postoperatively (p=0.2544)), but there was no significant difference among the groups afterwards.

Conclusion:   Steroid 10mg prednisolone that is 2 tablets of deltacotril is effective in reducing edema, limited mouth opening and pain after extraction of impacted mandibular wisdom teeth.

Keywords: Wisdom tooth, prednisolone, edema, limited mouth opening, pain.

 

INTRODUCTION

 

The extraction of impacted mandibular wisdom teeth is still the most common surgical procedure performed  by  oral and maxillofacial surgeons1.As it involves trauma to hard and soft tissue therefore beside severe complications such as  dysasthesia, severe infection, fracture and dry socket,  patients frequently complain  edema , limited  mouth opening and pain2,3. These post  surgical  complications can have a serious  impact  on  the  patient’s quality  of life4.  These are due to postoperative inflammatory response and the use of corticosteroids has gained wide acceptance.  Corticosteroid such as prednisolone may inhibit the initial step  in the synthesis of prostaglandins, leukotrienes and thromboxane related substances by inhibiting  the  conversion of phospholipids into arachidonic acid with a reduction of fluid  transudation  and  therefore edema5. Over several decades many  studies have reported the effectiveness of corticosteroids given before  or  just  after  removal  of third molars  in improving  recovery.4,6,10. A single    preoperative or postoperative intra-muscular dose   gives good plasma concentrations of the drug with prolonged anti-inflammatory action11. The anti-inflammatory effects of steroid after oral surgical procedures are well established. Since prednisolone has been shown to reduce post operative edema, it was decided to investigate the specific effects of prednisolone on swelling, limited mouth opening and pain following  extraction of impacted   wisdom tooth.

 

MATERIAL AND METHODS

 

This randomized controlled prospective trial study was conducted at the private clinics of the author and dental section of DHQ teaching hospital Kohat, Khyber Pukhtoonkhwa, Pakistan after review and approval from the institutional review board for bioethics (IRBB) Kust institute of medical sciences (KIMS) Kohat, from January 2011 to august 2011. Eighty patients were enrolled in this study, who presented themselves for extraction of bilateral impacted wisdom teeth. They were enrolled after taking history, thorough clinical examination and periapical x-rays were taken for all selected patients partially impacted wisdom teeth  with Class  II  or III occlusions  and  Pell and  Gregory  classification A, B or C on the  basis of radiograph were the inclusion criteria. Subjects had no pericoronitis or infection at the time of operation. Patients with contraindication to steroids, Peptic ulcer, diabetics, bacterial infections, history of thromboembolic events, glaucoma, psychosis, patients taking other medications chronically and pregnant ladies were excluded from the study. Written informed consent was obtained from each patient prior to enrollment.

As all 80 patients were  having  bilaterally impacted  mandibularwisdom teeth,   therefore in each  individual  one side was randomly assigned to the study  group  and the other  side  used as  control, thus  each  group  consisting of 80 impaction cases.  The study group received steroids   10mg prednisolone that is 2 tablets of deltacotril orally one hour before surgery, while the control received no such medication. Extractions of the two impacted teeth  (one  side  study  group   and  other   side control)  were  carried  out  at  six  weeks  interval. All patients were operated under local anesthesia by the author.  In most cases, ostectomy with tooth sectioning were performed.  All patients were given cephradine 500(velocef) mg 10 hourly orally for 5 days, and ibuprofen 400mg (brufen) orally as required for analgesia. They were also given a normal saline mouth rinse twice daily starting on the day after operation for 6 days.

A single examiner recorded edema,  mouth opening and  pain  before  and  after  each  surgical extraction of wisdom tooth. Clinical measurements were performed on 3rd and 6th days after the surgery.

Facial edema was  evaluated by  measuring the  distance from the  corner  of the  mouth  to the attachment of the  ear  lobe  following  the  bulge  of the  cheek, and  the  distance from the  outer canthus  of the eye to the angle  of the mandible. The preoperative sum of the two values (mm) was taken as the baseline for that side.

Limited mouth opening  was  recorded as  the  difference  in inter incisal  distance at maximum  mouth  opening before  and  after  the  operation. Severity of pain perception was assessed via a simplified visual analogue scale (VAS), 100 mm in length, where ‘0’ was  marked as ‘no  pain’ and ‘100’ as the most severe pain imaginable7. The significance of differences between the groups was calculated with the help of the Statistical Package for the Social Sciences (SPSS) version 12. Probabilities of less than 0.05 were taken as significant.

 

RESULTS

 

Among the 80 patients of bilaterally mandibular impacted wisdom teeth   there were 60 males and 20 females with male to female ratio of 3:1. The age range was 20-35 and the mean age was 22 years.

 

Table 1: Age and Gender distribution

Age (yrs)

Mean age(yrs)

Male

Females

Male: females

20-35

22

60

20

3:1

 

Total of 160 surgical   extractions were performed, 80 in control group and 80 in steroid group. At follow-up, no patients developed wound infection or serious post-operative complications and any drug side effect.

 

Table II: Mean measurements of edema, mouth opening and pain among the groups.

Variables

Control group

Steroids group

p-value

Edema (mm)

Day 3

Day 6

 

6.0

1.9

 

1.3

0.2

 

0.6862

 

 Mouth opening (mm)

Day 3

Day 6

 

6.5

4.5

 

24.5

35.8

 

 

 

0.2544

 

Pain(VAS)

Day 3

Day 6

 

8.5

6.5

 

3.3

0.5

 

 

0.1587

VAS= Visual analogue scale

 

There was a significant reduction in edema both on 3rd and 6th (p value=0.6862) post-operative days in study group as compared to controls. Limited mouth opening differed significantly between the study group and the control on 3rd post operative day but not on 6th day (p value=0.2544). There was also significant  reduction in pain post-operatively in study group as compared  to control  group(p value=0.1587) (Table  II).

 

DISCUSSION

 

The surgical  extraction of wisdom teeth is often associated  with severe postoperative  discomfort, even  when  teeth  are removed using a gentle  surgical  technique1.Perioperative use  of corticosteroids  is a  pharmacological  approach often  used to limit postoperative   edema , limited mouth opening,  and   pain after  extraction  of  impacted wisdom tooth due  to  their  suppressive action  on transudation11,12.   Numerous papers have supported their systemic use in third molar surgery8, 11, and 15. Recently, Mickiewicz et al16, in a  meta-analysis,  concluded that  giving  corticosteroids   preoperatively was  of mild to  moderate value  in reducing post  operative  inflammatory  signs  and  symptoms specifically patients given  corticosteroids had significantly less post operative edema and limited mouth opening than controls, both  early (after 1–3days) and  late (after 4–7 days).  In addition, those who took corticosteroids reported less pain postoperatively than control groups.  However,  the  effect  on  postoperative morbidity  and  the duration  of the effect of the corticosteroids varied  mainly as result  of lack of  consensus about  the  optimal  route,  dose, timing, and duration  of treatment in addition  to differences in methods used  to evaluate  clinical  variables.

Few  studies have  objectively  evaluated  the effect  of prednisolone as  an  intramuscular injection  in wisdom tooth  surgery,  although this route is the  one  most  likely to be  used  when  a  steroid injection  is prescribed in  outpatients. Intramuscular dosing studies have  suggested that  this route can  be  effective  if  a  single  dose  is given  either preoperatively or  postoperatively2,5,6.  The effect may be dose-dependent.  Some   authors suggested using prednisolone 10mg for the best results15.

 In this study oral prednisolone resulted in significant reduction in swelling post- operatively. This was as highly significant on the 3rd postoperative day, while maximum facial edema is expected after six days15.  The result of this study is in agreement with those of previous studies18,19,20.

Acute postoperative pain following wisdom tooth   extraction is predominantly a consequence of inflammation caused by tissue injury, 21.  Prednisolone in particular appears to decrease pain after surgery22.  This study shows a significant decrease in patients’ pain perception when comparing control to study group. This appears to be widely in agreement with the existing literature6, 7,9,10.

A statistically  high  significant  difference  between  study group  and  control  was observed overtime  for limited mouth opening  in this  study.  Test procedure did show  a reduced  postoperative degree  of limited mouth opening,  which  is in accordance  with other studies7,9,11,15.

 

CONCLUSION

 

10mg prednisolone that is 2 tablets of deltacotril given orally one hour before extraction of impacted wisdom tooth is an effective way of minimizing postoperative edema, limited mouth opening and pain.

 

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