Vol. 90 No.

4 October 2000

ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY

REVIEW ARTICLE

A review of perioperative corticosteroid use in

dentoalveolar surgery
Roger E. Alexander, DDS,a and Roger R. Throndson, DDS,b Dallas and Galveston, Tex
BAYLOR COLLEGE OF DENTISTRY, TEXAS A&M UNIVERSITY SYSTEM HEALTH SCIENCE CENTER, AND
UNIVERSITY OF TEXAS MEDICAL BRANCH

Objectives. Dental surgeons are often advised to use corticosteroids during and after third molar removal and other
dentoalveolar surgery to reduce postsurgical edema, but recommendations for use are rarely accompanied by definitive guid-
ance regarding the type of steroid, dosage, or duration of administration. Many regimens in use appear to be based on anec-
dotal information from articles in the 1960s and 1970s and might be subtherapeutic. Few regimens have been updated with
data from more recent studies, and well-designed comparison studies are lacking.
Study design. In this article, the literature from the past 30 years is reviewed, meaningful findings are highlighted, and avail-
able data are used as a basis for formulating interim clinical recommendations for corticosteroid use pending the emergence
of more evidence-based data. A meta-analysis of data was not performed.
Results. Recent data suggest that perioperative corticosteroid regimens should be administered in higher doses and for longer
durations than recommended in the past and should be started before surgery for optimum benefit.
Conclusions. Based on the literature review, interim recommendations for the use of corticosteroids are proposed, including
dosages and regimens that appear rational for oral, intramuscular, or intravenous corticosteroid administration before and after
extractions and other dentoalveolar surgery. These largely empiric recommendations might require adjustment when evidence-
based data become available in future studies. There is a great need for well-designed clinical research to further evaluate
protocols for corticosteroid use. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:406-15)

Many dentists routinely or episodically use cortico-
steroids for patients after dentoalveolar surgery, based
on generalized, nonspecific recommendations in many
textbooks, articles, and educational forums, although
the exact incidence of usage is unstudied. Rarely are
specifics mentioned regarding the type, dosage, and
duration of administration, and the guidance does not
appear to be founded on evidence-based studies.
Despite dozens of published articles, relatively little
reliable data are available for formulating a scientifi-
aProfessor, Department of Oral and Maxillofacial Surgery and
Pharmacology, Baylor College of Dentistry, Texas A&M University
System Health Science Center, Dallas, Tex.
bAssistant Professor, Oral and Maxillofacial Surgery Division,
Department of Surgery, University of Texas Medical Branch,
Galveston, Tex.
Received for publication Dec 28, 1999; returned for revision Mar 24,
2000 and May 4, 2000; accepted for publication Jun 20, 2000.
Copyright © 2000 by Mosby, Inc.
1079-2104/2000/$12.00 + 0 7/12/109778
doi:10.1067/moe.2000.109778
cally sound philosophy regarding the use of cortico-
steroids to control postsurgical sequelae in dentistry.
Our objective is to review the available contemporary
literature and use that information to formulate some
interim suggestions for the rational use of cortico-
steroids during and after dentoalveolar surgery until
further studies can clarify these issues and provide
additional evidence-based guidelines on dose form,
dosages, and duration of administration.
SEARCH STRATEGY AND SELECTION
CRITERIA
Conventional electronic databases were searched for
articles published in the last 30 years on the topic of
drug use for limiting postsurgical edema. Studies
published before 1970 were not included unless they
had some specific contribution because drugs and
surgical procedures and equipment have changed over
time, and older studies might no longer be relevant to
current practices. The identified articles were not
subjected to any type of definitive data analyses; there-

406
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 4
fore, this article should be considered a comprehensive
literature review, not a meta-analysis.
THE PHYSIOLOGY OF OROFACIAL
POSTSURGICAL EDEMA
Surprisingly, some dentists consider edema a compli-
cation rather than a normal physiologic reaction to
insult and injury. When body tissues are injured,
regardless of the cause, the normal physiologic
response is inflammation, leading to edema. Edema, in
varying amounts, will occur after every surgical inter-
vention and should be expected. The only questions
concern how much edema will occur and where it will
occur. The reader is referred to Hupp’s discussion in a
leading contemporary oral surgery textbook1 or to the
article by Patten et al2 for further information on the
pathophysiology of wound healing and inflammation.
Prostaglandins also might play a minor role in edema
formation but do not appear to be the sole factor
involved.3 Studies are currently underway to clarify
their precise role in the process.
Edema occurs as osmotic pressures rise, capillary
permeability is altered, transudation of fluid occurs
through vessels into the area of damage, and the local
lymphatic system becomes obstructed by fibrin and
fibrinogen clots derived from plasma and adjacent
injured tissues. Fluid then accumulates in the intersti-
tial spaces. In most cases, greater degrees of tissue
injury lead to greater amounts of edema.1,3 Hupp3 also
notes that edema is variable from area to area and will
accumulate more freely in areas of loose connective
tissues, whereas tissues that are tightly bound down to
underlying structures tend to have less swelling.
Postsurgical facial edema is difficult to quantify accu-
rately because it involves 3 dimensions of measurement
with an irregular, convex surface and can manifest itself
internally as well as externally. To the subjective
observer, lean patients appear to have more swelling
develop than patients who are “portly,” “plump,”
“stout,” or obese.4 Messer and Keller4 also state that
redheaded, blonde, and fair-skinned patients swell more
than dark-complexioned patients. Over the years,
numerous researchers have tried various measurement
techniques in an effort to objectively measure edema
and make comparisons between patient populations.
Most are indirect assessments of the altered contours of
the skin surface. Measurement tools mentioned in the
literature have included visual analog scales, trismus
recordings (which are not generally reliably related to
edema), standardized stereo radiographic or photo-
graphic measurements, computerized tomography,
modified face bow devices, ultrasonography, facial
plethysmographs, or various other ways of taking direct
facial measurements.5-12 Few of these methodologies
Alexander and Throndson 407
have been validated for accuracy, reproducibility, or
statistical reliability. Because many different method-
ologies are used, data from one study cannot be easily
compared with data from other studies. Intraoral
swelling is even more difficult to measure.
Surgical experience and difficulty are recognized as
significant factors in the incidence and severity of post-
operative complications (including edema) after
dentoalveolar surgery.3,13-16 Inexperienced doctors will
generally encounter more postoperative edema than
highly experienced surgeons, all other variables being
equal, even when procedures are of short duration and
tissues are handled gently.
The precise duration of the edema response to oral
surgery has not been well documented and is probably
variable from patient to patient and procedure to proce-
dure. Laskin16 states that edema maximizes in 24 to 48
hours, but Peterson17 says it usually maximizes in 48 to
72 hours and is usually resolved after the first postop-
erative week. Any postoperative swelling that
continues to expand after 3 days is thought to be addi-
tional swelling resulting from infection and is not post-
operative edema.17 A 2-day to 3-day time frame is most
frequently cited and is consistent with published
studies. Excessive activity on the part of the patient
might theoretically increase the amount of edema, but
we are unaware of any reliable data that compare the
edema responses of resting versus physically active
patients after maxillofacial surgery.
CORTICOSTEROID USE TO CONTROL
EDEMA
Corticosteroids are well-known adjuncts to surgery
for suppressing tissue mediators of inflammation,
thereby reducing transudation of fluids and lessening
edema.3,13 Some reduction of postoperative pain
generally accompanies a reduction of edema, and corti-
costeroids have some inhibitory effects on
prostaglandins. But steroids alone do not have a clini-
cally significant analgesic effect.4,8,10 In fact, the use of
steroids might increase the patient’s reaction to pain by
suppressing β-endorphin levels.18 Many patients also
experience a mild euphoric, or mood altering, effect
from steroids that theoretically might help them cope
with postoperative sequelae,19,20 but this effect is
poorly studied in postsurgical dental patients and might
be highly variable. Long-term use of steroids can delay
healing and increase susceptibility to infection, but
these effects are not clinically significant with the
typical short-term usage protocols in oral surgery.21
Anti-inflammatory effects
Generally speaking, to gain the desired anti-inflamma-
tory effects, corticosteroids must be administered in
 408 Alexander and Throndson
doses exceeding the normal physiologic amounts
released by the body.20 Although most administered
corticosteroids are eliminated from the blood in less than
24 hours, some late anti-inflammatory effects have been
alleged to linger for up to 3 days.21 The mechanisms of
actions of corticosteroids are not completely understood,
but recent research has further enhanced our under-
standing. Research has shown that steroids with a ketone
at the C11 position are metabolized by the liver into an
active 11-hydroxyl form that is necessary for most of the
glucocorticoid effects of the drugs.22 Steroids have been
shown to reduce levels of lymphokines, prostaglandins,
serotonin, bradykinins, cortisol, migratory inhibiting
factor, and β-endorphins.18,22-24 Steroids are also
involved in the synthesis of immunoreactive and regula-
tory proteins, including vasocortin, angiotensin-
converting enzyme (which degrades bradykinin) and
lipocortin.23-24 Some authors state that steroids stabilize
cellular membranes and have a suppressive effect on
lymphocytes, monocytes, and eosinophils.1,20,22 An in-
depth review of the pharmacotherapeutics of cortico-
steroids is beyond the scope of this article, and the thera-
peutic effects of corticosteroids are summarized
elsewhere.1,19,21,22
The body’s natural glucocorticosteroid is hydrocorti-
sone, also called cortisol. The normal daily output by
the adrenal glands is reported to be between 15 mg and
30 mg, but up to 300 mg can be supplied in times of
crisis.20,21,25 Steroids also have numerous other desir-
able effects and side effects with which clinicians
should be familiar before using the drugs.
Common forms
The most commonly used forms of corticosteroids
in dentoalveolar surgery include dexamethasone
(oral), dexamethasone sodium phosphate (intra-
venous or intramuscular Decadron Phosphate,
Decadrol, Dexone, Hexadrol Phosphate, and others),
and dexamethasone acetate (intramuscular Decadron-
LA and others); methylprednisolone (oral Medrol,
Meprolone), methylprednisolone acetate (Depo-
Medrol and others); and methylprednisolone sodium
succinate (intravenous or intramuscular Solu-Medrol
and others).3,13,25 Dexamethasone has a longer dura-
tion of action than methylprednisolone and is consid-
ered more potent.11 Authors have also recommended
the use of betamethasone sodium phosphate
(Celestone Phosphate), 11,26 but this form has no
apparent advantage over dexamethasone. A combina-
tion form of betamethasone exists, where short-
acting (sodium phosphate) and long-acting (acetate)
forms are used together, but we have not located any
studies that substantiate any additional surgical
benefit from that combination.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
October 2000
All these forms have nearly pure glucocorticoid
effects and virtually no mineralocorticoid effects.19
Dexamethasone and methylprednisolone reportedly
also have the least adverse effects on leukocyte chemo-
taxis.13 The longer-acting forms will generally have a
more depressing effect on the adrenal glands. Dosages
of methylprednisolone of ≤40 mg will reportedly not
produce any adverse systemic effects.27
Contraindications
Corticosteroids are said to be absolutely contraindi-
cated for use in patients with active or incompletely
treated tuberculosis, active viral or fungal infections
(especially ocular herpes), active acne vulgaris,
primary glaucoma, or patients with a history of acute
psychoses or psychotic tendencies.1,25,28 However,
the recommendations are primarily based on long-
term chronic steroid use rather than single-dose or
short-term use.21,22 Nevertheless, it is prudent to
minimize use in these patients until more data emerge
on the risks of short-term usage. Because some
formulations of steroids contain methylparaben or
sulfites, allergic reactions are possible in susceptible
patients.22 There have been at least 30 documented
allergic reactions and numerous side effects reported
in the literature.25
Preoperative medical consultation might be prudent
for patients with diverticulitis, peptic ulcers, Cushing’s
syndrome, renal insufficiency, uncontrolled hyperten-
sion, uncontrolled diabetes mellitus, pregnancy, lacta-
tion, acute or chronic infections, or myasthenia
gravis.1,20,25,28 The adverse effects on hypertension
and glaucoma are related to mineralocorticoid activity
and are not a problem with the newer derivatives, such
as methylprednisolone and dexamethasone.19
Systemic side effects
Steroids should not be used casually. As in any other
aspect of the healing arts, the risks need to be weighed
against the anticipated benefits of use. Since the early
1970s, several authors have expressed concern over
the theoretical dangers of adrenal suppression, infec-
tion, and interference with the immune system when
steroids are used to control edema. At least 3 authors
have suggested that the side effects should contraindi-
cate the use of steroids after minor procedures, but
these views are not well supported in the litera-
ture.16,21,29 The data have disproved any significant
risks when corticosteroids are used as a single dose or
are confined to protocols of less than 3 to 5
days.20,21,25 Most systemic effects, such as changes in
levels of sodium, potassium, or plasma cortisol, are
minor, transient, and do not exceed the normal ranges
of variation.30 Sisk and Bonnington31 noted that
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Alexander and Throndson 409
Volume 90, Number 4

Table I. Comparisons between various corticosteroids

Corticosteroid Equivalent dose 1 Equivalent dose 2 (dose 1 × 4) Biologic half-life Available forms
Cortisone 25 mg 100 mg 8-12 h V, M, O
Hydrocortisone
(Cortisol) 20 mg 80 mg 8-12 h V, M, O
Methylprednisolone 4 mg 16 mg 18-36 h V, M, O
Dexamethasone 0.75 mg 3 mg 36-54 h V, M, O, L
Betamethasone 0.6-0.75 mg 2.4-3.0 mg 36-54 h O, L
V, Intravenous; M, intramuscular; O, oral; L, liquid form.

Table II. Brands, dose forms available

Corticosteroid Form Dosage available Brand names
Methylprednisolone O 2, 4, 8, 16, 24, 32 mg Medrol
Methylprednisolone acetate M 20, 40, 80 mg Depo-Medrol, depMedalone,
Depoject, Depopred, M-Prednisol,
Duralone, Medralone
Methylprednisolone sodium succinate V, M 40, 125, 500 mg, 1 g, 2 g Solu-Medrol, A-Methapred
Dexamethasone O, L 0.25, 0.5, 0.75, 1, 1.5, 2, 4, 6 mg Decadron, Dexameth, Dexone, Hexadrol
Dexamethasone acetate M 8 mg/mL Decadron-LA, Dalalone LA, Decaject-LA,
Solurex LA, Dexasone LA, Dexone LA,
Cortastat LA
Dexamethasone sodium phosphate (V),* M 4, 10, 20, 24 mg/mL Decadron Phosphate, Dalalone, Decaject,
Dexasone, Dexon, Hexadrol Phosphate,
Solurex, Cortastat
Betamethasone O, L 0.6 mg Celestone
Betamethasone sodium phosphate V, M 4 mg Celestone, Cel-U-Jec
V, Intravenous; M, intramuscular; O, oral L, liquid.
*One form for IV use; other forms are IM only.

single-dose therapy does not really increase suscepti-
bility to infection but can delay the diagnosis of infec-
tion by masking some signs and symptoms. All
hormone levels return to normal by the seventh post-
operative day in the typical protocols.8,28 The use of
oral forms might cause gastrointestinal upset, and
steroids are best taken with food.25 Finally, cortico-
steroids can cause depression or psychoses in certain
patients, but this effect is fairly unpredictable.
Equivalency
The various steroid preparations are not equal in
potency or duration of effect. One hundred milligrams of
cortisone is equivalent to 80 mg of hydrocortisone
(cortisol, the body’s natural product), 16 mg of methyl-
prednisolone, and 3 mg of dexamethasone or betametha-
sone.21 Hydrocortisone use is limited by its short biologic
half-life of 8 to 12 hours. Methylprednisolone has an
intermediate half-life of 18 to 36 hours, whereas dexam-
ethasone and betamethasone have longer half-lives of 36
to 54 hours.19 The acetate forms have low solubility that
acts as a sustained-release depot for 1 to 2 weeks (peak
effect, 4-8 days), giving these forms some clinical advan-
tage when a longer effect is needed (Tables I and II).
LITERATURE REVIEW FINDINGS
In a 1969 study by Hooley and Francis,26 patients
who received prophylactic oral betamethasone imme-
diately before surgery experienced much less edema,
50% less pain, and used 50% less pain medication after
surgery than the control group. In a 1975 article,
Messer and Keller4 subjectively noted a “significant”
decrease in clinical swelling, pain, and trismus in 500
patients by using 4 mg of intramuscular dexametha-
sone immediately after surgery. Huffman32 reported a
statistically significant decrease in early edema in
patients who were given 125 mg of intravenous
methylprednisolone immediately before surgery, but
they noted no difference after 1 week. Hargreaves and
Costello24 noted a 62% decrease in immunoreactive
bradykinin release 3 hours after surgery by using 125
mg of methylprednisolone.
Several authors have noted limited responses to
single doses of steroids. Gersema and Baker20 provide
a good review of reported cases. Skjelbred and
Lokken11 studied postoperative swelling after the use
of 9 mg of intramuscular betamethasone immediately
before surgery. Their data reflect a 55% reduction of
swelling on the third postoperative day and a 69%
 410 Alexander and Throndson
Table III. Recommended interim protocols for the use of prophylactic corticosteroids after third molar extractions
and other minor oral procedures in adult patients
Protocol Drug(s) used
Intramuscular (IM) Methylprednisolone acetate (MPA), 40 mg/mL
Methylprednisolone 8-mg tablets (optional) (2 total)
Possible alternate drug: dexamethasone acetate
(DMA), 8 mg (unstudied protocol)
Intravascular (IV) Methylprednisolone sodium succinate
(MPSS), 125 mg/mL
Methylprednisolone tablets, 8 mg (Rx 8 total)
Alternate regimen: dexamethasone sodium phosphate
(DSP), 8-12 mg IV/IM
Dexamethasone tablets, 4 mg (Rx 8 total)
Oral Dexamethasone tablets, 4 mg (Rx 10-12 total)
reduction on the sixth postoperative day in 23 of 24
patients in the steroid group. Pedersen33 noted a 50%
decrease in swelling on the second postoperative day
with the use of 4 mg of intramuscular dexamethasone,
but noted no significant differences on the seventh day
after surgery. Her patients also used fewer analgesics.
By using a single preoperative dose of 20 mg of
methylprednisolone, Milles and Desjardins10 noted a
42% decrease in swelling on the first day after surgery,
34% less on the second day, but only 19% less on the
third day after surgery. Schaberg et al9 also noted as
much as a 62% decrease in edema 24 hours after
orthognathic surgery by using 1 mg/kg of intravenous
methylprednisolone, but they noted no significant
differences after the second postoperative day. Neupert
et al12 noted no benefit after administration of 4 mg of
intravenous dexamethasone immediately before
surgery, although this is now recognized as a subthera-
peutic dose.10,19,20 Beirne and Hollander8 noted
decreased edema the first day after surgery by using a
single intravenous dose of 125 mg of methylprednisolone
immediately before surgery, but they noted a rebound
increase in edema on the second and third postoperative
days. Numerous authors emphasize the need for a longer
duration of dosing to extend the benefits of the drug
throughout the period of edema formation. According to
Matheny,34 tapering of oral doses is not necessary unless
high doses for more than 3 to 5 days are used.
Bystedt and Nordenram29 noted no statistically signif-
icant differences in swelling from a placebo group after
the use of 12 mg of oral methylprednisolone before
surgery and 4 mg twice a day for 2 days after surgery.
Again, this was most likely because of the subthera-
peutic doses used in the study. Edilby et al30 noted no
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
October 2000
Evening before surgery
AM case: (optional) (2) 8-mg tablets,
methylprednisolone, at bedtime
PM case: Give nothing
Alternate drug: Give (2) 4-mg tablets, dexamethasone
at bedtime
AM case: give nothing
PM case: give nothing
AM case: (2) 4-mg tablets, dexamethasone, at bedtime
PM: nothing (see day of surgery, PM case)
significant effect when using 4 mg of intramuscular
dexamethasone immediately before and 1 day after
surgery. These results underscore the need for higher,
longer dosages to gain significant benefits from the anti-
inflammatory aspects of the corticosteroids.10,13,19,20,25
Dosage and duration of use
The dosage and duration of action of the glucocorti-
costeroids have clinically significant effects on the
overall amount of swelling after surgery. As with any
other medications, steroids must be used properly to
derive the maximum anticipated benefit. These criti-
cally important effects are rarely addressed in refer-
ences advocating postoperative steroid use and include
the following:
• All steroids must be administered before the inflic-
tion of tissue damage (several hours before, in oral
usage), not during or after surgery.3,21,23 Oral forms
must be given at least 2 to 4 hours in advance of the
procedure to allow for adequate tissue levels.21,23,24
Peak levels for bradykinin release occur within 3
hours after tissue trauma.24 Few data exist on the
subject of optimal lead times for preoperative intra-
muscular administration.
• A higher steroid dose will yield more satisfactory
results.10,19,20 Gersema and Baker20 state the steroid
dosage should exceed the maximum daily output,
equivalent to 300 mg of cortisol, for maximum effect.
Gersema and Baker20 and Beirn and Hollander8
recommend the administration of a high-loading dose
of 125 mg of methylprednisolone parenterally (a
dosage that is equivalent to 23 mg of dexametha-
sone). This dose has yielded the best results and has
not created any clinically significant problems for
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 4
Day of surgery
AM case: MPA, 40 mg IM immediately before surgery after local
anesthesia administration (or DMA, 8 mg, unstudied protocol)
PM case: (2) 8-mg tablets, methylprednisolone in AM, 3-4 h
before appointment, then MPA, 40 mg IM immediately
before surgery after local anethesia adminstration
AM case: MPSS, 125 mg IV or DSP, tablet, 8-12 mg IV at
start of case
PM case: MPSS, 125 mg IV before start of case or 8-12 mg DSP
IV at start of case
If MPSS used: (2) 8-mg tablets, methylprednisolone, at bedtime
If DSP used: nothing at bedtime
AM case: (4) 4-mg tablets, dexamethasone, 3-4 hours prior to
appointment start
PM case: (4) 4-mg tablets in AM, 3-4 hours prior
to appointment start
Both: (2) 4-mg tablets, dexamethasone at bedtime
patients without contraindications. Messer and
Keller4 recorded no side effects when up to 12 mg of
dexamethasone or equivalent were administered.
• Rebound swelling can occur if the duration of use is
inadequate; therefore, it is important to maintain
levels of short-duration steroid formulations for
more than 1 day.9,10,12,13,19,25 Peterson13 and Milles
and Desjardins10 state there is a need to continue
corticosteroid therapy for a minimum of 3 days
because swelling in patients treated with steroids
does not appear to peak until the third day after
surgery. This has not been well studied, however.
With most forms, single-use steroid effects wear off
after the first day, and rebound edema occurs. Milles
and Desjardins10 recommend a sustained release
form of steroid, such as Depo-Medrol (methylpred-
nisolone acetate) in a higher single dose of 40 mg. A
study by Huffman32 did not show any statistically
significant clinical differences between the use of 40
mg and 125 mg doses of methylprednisolone. The
alternative is to place the patient on a multiple-day
dosage regimen of an oral corticosteroid after
surgery. Tapering of doses is not mandatory in short-
term dosing.21,34 Follow-up dosage requirements
have not been adequately studied.
• Use of usual dosages of corticosteroids over 3 to 4
days has no significant adverse effects on healing
and they do not suppress adrenal function to a signif-
icant degree.20,21,25,28 Cortisol levels return to
normal value in 5 to 7 days.8,28 Many authors refer
to administering a high dose, followed by an abrupt
discontinuance or rapidly tapering doses as “pulsed
therapy.”19,28 However, this is generally associated
with therapeutic, not prophylactic, use.
Alexander and Throndson 411
First day after surgery Second day after surgery
Nothing Nothing
MPSS case: (1) 8-mg tablet (1) 8-mg tablet
methylprednisolone, every 6 h (4 total) methylprednisolone
Alternate: dexamethasone (4) 4-mg every 6 h (4 total)
tablets in AM Alternate: nothing
(4) 4-mg tablets, Nothing
dexamethasone in AM
Timing
If unexpected intraoperative difficulty is encountered
in removing a tooth, the question is raised of whether it
is useful to inject corticosteroids at that point in the
case? Studies suggest that if an intravenous form is
used, some limited benefits are derived, even if the
steroid is begun after surgery.4,25 The steroid should be
administered as soon as the need is realized during
surgery. There is a chance for some benefit, and there
is no significant risk unless the patient has one of the
specified contraindications. The benefits of using an
intramuscular form during surgery are less likely to
occur because of the delay in tissue uptake.
In a typical practice setting, administering cortico-
steroids 3 hours before surgery is usually not convenient.
As a matter of convenience, many surgeons use the intra-
venous form of the drugs in conjunction with intravenous
sedation or the intramuscular form with local anesthesia.
An additional benefit is that the parenteral regimen
removes any potential compromises caused by patient
noncompliance. The protocol suggested by Milles and
Dejardins10 seems appropriate, in which the patient is
started on an oral dose the night before surgery, then is
given an intramuscular dose immediately before surgery.
Despite less-than-optimal timing, Messer and Keller4 gave
the intramuscular steroid immediately after surgery and
reported good results. Nevertheless, several studies have
shown that giving intramuscular or intravenous steroids
before the procedure yields more significant results than
starting the steroids after the procedure has finished or not
using steroids at all.4,8,10,32 If oral corticosteroid therapy is
started at least 3 to 4 hours before the surgery and is
continued for at least 2 days after surgery, it can be nearly
as effective as parenterally administered forms.10,13,19,23,25
 412 Alexander and Throndson
We are unaware of any published data related to the
timing of the appointment (AM or PM) relative to a
preoperative dose the night before, or whether a
supplemental dose should be administered the morning
of surgery when the patient has an afternoon appoint-
ment. Logic would seem to support such use.
Effects of nonsteroidal anti-inflammatory drugs
Recent studies have suggested that the anti-edema
benefits of corticosteroids for patients after surgery
might be further enhanced by the use of nonsteroidal
anti-inflammatory drugs (NSAIDs), such as ibuprofen
and flurbiprofen.5,6 This is countered by other
authors.7,23,31 They note that the anti-inflammatory
effects of NSAIDs take several days to evolve, and
prostaglandins play only a minor role in edema.5,35
Schultze-Mosgau et al6 reported the combination of
double-dosed oral methylprednisolone and ibuprofen
reduced swelling by 58% (by visual analog scale; 56%
by using ultrasonography) over patients who used
placebos.6 Their conclusions were contradicted by
Hargreaves,23 who noted a lack of evidence that the 2
drugs were potentiated and expressed concern that the
combination of drugs could potentially increase
gastrointestinal side effects. It is unknown whether
such a gastrointestinal effect is a significant risk with
short-term use, however. Sisk and Bonnington31 note
no significant effect of flurbiprofen on edema at 72
hours when it is used with 125 mg of methylpred-
nisolone, although it did provide improved analgesia.
Ücok7 showed that the NSAID tenoxicam, which was
not administered along with a steroid, was no more
effective than placebo in modifying swelling during the
first 2 days after surgery. Troullos et al5 showed that
NSAIDs alone have only a minor anti-edema effect.
Several studies have noted an increase in swelling
after dental surgery with the use of aspirin. Skjelbred
and Lokken 11 noted a 50% increase in swelling
(versus the use of acetaminophen). A news item in the
California Dental Association Journal cites a study
from the Academy of General Dentistry that showed a
55% increase in swelling after aspirin use.36
Routine concurrent antibiotic use
Evidence is lacking for the routine concurrent use
of prophylactic antibiotics for prevention of infection
along with the use of corticosteroids. It is beyond the
scope of this article to discuss the rationales of
prophylactic antibiotic use. Capuzzi et al,37 among
others, show that the use of routine antibiotic prophy-
laxis is not justified, whether corticosteroids are used
or not, and does not significantly reduce the postop-
erative sequelae.37 A study by MacGregor and Addy38
showed that the use of systemic penicillin was shown
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
October 2000
to be of slight advantage only in the most difficult
cases. Therefore, we believe that the use of antibiotics
should be based on the amount of surgical trauma
inflicted, not solely because of corticosteroid use.
INTERIM RECOMMENDATIONS FOR
DENTAL SURGERY USE
Although many authors anecdotally advocate the
use of corticosteroids to limit postoperative edema,
few authors have made definitive recommendations.
Consequently, protocols have evolved by word of
mouth, and many regimens in common use might be
subtherapeutic and of limited benefit. Based on the
data reported in various studies, we believe newer
information suggests a need to change some of the
protocols that are based on studies from the 1960s
and 1970s. As noted previously, higher doses of
steroids are indicated, and the studies showing
rebound swelling on the second and third days afer
surgery suggest a need for longer courses of prophy-
lactic steroids in most cases. By using this guidance,
we recommend the following interim regimens for
prophylactic corticosteroid administration, until
future studies can provide additional data (Table III).
Intramuscular
A 1-time depot intramuscular form, such as 40 mg
methylprednisolone acetate (Depo-Medrol and others,
40 mg/mL) is advantageous, as recommended by
Milles and Desjardins10 and Montgomery et al.19 The
drug can be injected before surgery into the deltoid,
gluteus, masseter, or medial pterygoid muscle on one
or both sides, immediately after administration of seda-
tion or local anesthesia. If injected intraorally before
local anesthesia administration, it is quite uncomfort-
able. As an alternative, 8 to 12 mg of dexamethasone
acetate (Decadron-LA and others) can be administered
instead of Depo-Medrol. Depo-Medrol or Decadron-
LA should never be injected intravenously; they are
intended for intramuscular use only.
Montgomery et al19 note that administration of a
high dose of steroid intramuscularly into the masseter
muscle has not been shown to improve anti-inflamma-
tory actions over injections at distant sites, but there is
a convenience factor for the surgeon to use an intraoral
site. One article also suggests the steroid can be
injected into buccal vestibule tissues,1 although we do
not know of any clinicians who do so.
In keeping with the recommendations to administer
oral doses at least 3 to 4 hours before surgery, a preop-
erative dose of two 8-mg methylprednisolone tablets or
two 4-mg dexamethasone tablets can be considered at
bedtime the night before surgery (for AM cases), or
early the morning of surgery (for PM cases), to achieve
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 4
optimal benefit. This is then followed with the intra-
muscular dose at the start of surgery, although the
optimal lead time for the intramuscular dosing is not
well established.
The use of 8 to 12 mg of the dexamethasone acetate
form (Decadron-LA and others), a long-acting, reposi-
tory form, might have therapeutic advantages, but we are
unaware of any clinical studies that have evaluated the
efficacy and safety of that particular drug form in
dentistry. It seems logical that this would be a viable
alternative drug form, and it is interesting that its use has
not been studied. Clinical studies are therefore needed.
Intravenous
Methylprednisolone sodium succinate, 125 mg (Solu-
Medrol and others), or 12 mg of dexamethasone sodium
phosphate (Decadron and others) are favored by many
for intravenous administration. A popular protocol is 125
mg of methylprednisolone sodium succinate intra-
venously immediately before surgery. Oral preoperative
doses have not been proven necessary when the loading
dose is administered intravenously. Although Gersema
and Baker20 do not believe follow-up dosing is necessary,
we believe if the drug is used for a morning case, then the
injection ideally should be followed by two 8-mg tablets
of oral methylprednisolone (Medrol) the evening after
surgery because of the shorter biologic half-life of the
drug. Then, one to two 4-mg tablets of methylpred-
nisolone is given 4 times daily during the first and second
days after surgery. Although this dosage protocol has not
been statistically verified, it is consistent with clinical
recommendations of others.13,16 Follow-up doses of
dexamethasone and betamethasone are not required
because of their longer half-lives. Tapering of dosages is
not necessary because of the short regimen durations.34
If either of the longer-acting dexamethasone or
betamethasone forms is used by the surgeon, we recom-
mend a minimum preoperative loading dose of 8 to 12
mg (4 mg/mL) because some studies have shown little to
no edema reduction with only 4 mg.12,13 This dose
should ideally be followed by four 4-mg tablets of oral
dexamethasone on the morning of the first day after
surgery. Because the elimination half-life of these drugs
is 36 to 54 hours, theoretically it should not be necessary
to continue the follow-up dosing beyond the morning of
the first postoperative day. Administration of steroids as
a single large dose each day minimizes the side effects
and causes less adrenal suppression.21 This recom-
mended dosage level is 8 mg of dexamethasone per day,
which is slightly higher than the recommendations of 4
to 6 mg per day from other authors.21,30,33 Again, this
aspect has not been studied in controlled clinical
research and should be considered an interim recom-
mendation, pending more evidence from future studies.
Alexander and Throndson 413
Oral
If oral administration is planned, the regimen should
generally begin the night before surgery or the morning
of surgery (for an afternoon surgery) because studies
have shown that at least 2 to 4 hours is needed for orally
administered steroids to become effective.21,23 Dexa-
methasone is our favored oral form, with two 4-mg
tablets at bedtime the evening before surgery, a three to
four 4-mg tablet loading dose preoperatively on the day
of surgery, and a single follow-up dose of three to four
4-mg tablets on the morning of the first and second days
after surgery. Again, this empiric regimen is based on
the review of the literature and lacks statistical
verification. The recommendation should be considered
for use only until more research data emerge.
DISCUSSION
Corticosteroid use should not be routinely used after
every dentoalveolar surgery, even for mildly difficult
cases. Rather, it should be reserved for selected cases
where a significant amount of surgical trauma is antic-
ipated before surgery or serendipitously encountered
during surgery. Examples of this include deeply
impacted teeth; large teeth with weakened coronal
structure or widely divergent roots, which are
embedded in dense bone; multiple extraction cases
with extensive alveolar remodeling (such as alveo-
plasty or tori removal); vestibuloplasties; block resec-
tions; and other similarly extensive surgical proce-
dures. Data on the benefits of use, if any, in
orthognathic and cosmetic surgery are still emerging.
Anecdotally, many surgeons often anticipate greater-
than-usual swelling in patients with lighter complex-
ions and lighter natural hair color because these
patients seem to be more reactive, as noted by Messer
and Keller.4 We have noted similar clinical observa-
tions in our practices, but we are unaware of any scien-
tific data that compare postsurgical edema in patients
of differing complexions, so little objective verification
exists for this clinical impression. Some authors have
also stated that women appear to experience more post-
operative edema than men, but this, too, is unproven.
Research needs
There are still no precise, evidence-based answers to
many questions concerning steroid use, despite the many
articles written since the 1960s. Most articles compare
the use of a single steroid with a placebo group, but few
articles have compared various steroids or steroid regi-
mens to discern which is the most effective form and
what the minimal dose is that provides maximum benefit
with minimum risks. Well-designed prospective clinical
studies are needed to help answer several key questions:
• Do darker-complexioned and darker-haired patients
 414 Alexander and Throndson
truly experience less swelling than lighter featured
patients?
• Do obese patients have more clinical swelling than
lean patients?
• Do women routinely experience more postsurgical
edema than men?
• Do patients who rest quietly after surgery experience
less edema than physically active patients?
• Is it necessary to continue oral dosages to the third
postoperative day, or could the regimen be continued
for only 1 day after surgery?
• How long before surgery should intramuscular corti-
costeroid forms be administered for optimal effect?
• Is an oral preoperative dose the night before surgery
significantly beneficial?
• Which dosages of oral steroids are the most optimal
for the follow-up regimens?
• Is an intravenous-plus-oral dexamethasone regimen
clinically superior to a single-dosed methylpred-
nisolone acetate regimen, or vice versa?
• Is the longer acting, acetate form of dexamethasone
clinically equal or superior to its methylprednisolone
counterpart?
• What is the optimal dosage in an oral dexamethasone
regimen?
• Does the available combination form of short-acting
and long-acting betamethasone offer any clinical
advantages?
• Which one of the many recommended techniques
from past studies for quantifying edema is the most
accurate?
We must have a standardized and verified means of
comparing future data. None of these issues have been
well explored, in our judgment.
CONCLUSIONS
The use of corticosteroids to reduce edema after
dentoalveolar surgery is widely recommended and prac-
ticed, but should not be done routinely. Rather, the tech-
nique should be used for select cases where significant
surgical trauma is inflicted or the patient is judged to be
at risk for excessive edema. In routine cases, surgical
skills and attention to operative details should be
adequate to keep postoperative edema at acceptably low
levels. When steroids are used, they should be started
before the surgical procedure, should be given at higher
dosages and should either be used in a long-acting form
or be used as a supplemental follow-up to extend steroid
coverage for at least 2 days after surgery. Such usage
should not interfere with healing and will not signifi-
cantly impair adrenal function. Recommended regimens
are summarized in Table III, but should be considered
empiric and interim until data emerge from future
controlled studies. The benefit of using NSAID medica-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
October 2000
tions in combination with corticosteroids to increase
edema reduction is not well supported in the literature.
The use of antibiotics for patients receiving short-term,
prophylactic corticosteroids should only be considered
in cases where the high risk of postoperative infection
clearly outweighs the risks of use or for patients who are
immunocompromised.
We thank Tommy W. Gage, BS, DDS, PhD; Robert G.
Triplett, DDS, PhD; and Sterling R. Schow, DMD for their
reviews of the manuscript and insightful comments.
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