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Oral Surgery ISSN 1752-2471

ORIGINAL ARTICLE

Use of dexamethasone to minimise post-operative sequelae after

third molar surgery: comparison of five different routes of
administration
O.W. Majid & W.K. Mahmood
Department of Oral and Maxillofacial Surgery, College of Dentistry, University of Mosul, Mosul, Iraq

Key words: Abstract

post-operative sequelae, submucosal
dexamethasone, third molar surgery Aim: The aim of this randomised non-blind prospective study was to
compare the effect of dexamethasone sodium phosphate 4 mg in five dif-
Correspondence to: ferent routes of administration on post-operative sequelae and quality of
Dr OW Majid
life (QOL) measures for patients undergoing surgical removal of impacted
Department of Oral and Maxillofacial Surgery
College of Dentistry
lower third molars.
University of Mosul Material and methods: A total of 72 patients (32 males and 40 females)
Mosul were included in the study and were randomly divided into six equal study
Iraq groups: five treatment groups received dexamethasone 4 mg as intramus-
Tel.: +0964 06 812910 cular injection, intravenous injection, oral tablets, submucosal injection
Fax: +0964 06 812900 and endoalveolar powder; and control group which received no dexam-
email: omerw_majid@yahoo.co.uk
ethasone. Swelling, trismus and pain were evaluated at the first, third and
Accepted: 19 May 2013
seventh day post-operatively. A modified questionnaire was used to
measure different aspects of QOL.
doi:10.1111/ors.12049 Results: All dexamethasone groups showed statistically significant
improvement in swelling and pain at all intervals (P < 0.05) and in trismus
Clinical relevance at day 1 and day 3 intervals (P < 0.05) as compared to control. QOL meas-
Scientific rationale for study: Many methods ures also showed significant improvement (P < 0.01). Results among treat-
have been tried to ‘smooth’ post-operative
ment groups were comparable for all parameters. No relevant side effects
period after surgical extraction of impacted third
molars, including pharmacological means. Local
were seen nor reported.
application of dexamethasone seems to be a Conclusions: Local routes of dexamethasone administration showed com-
simple and effective way. Quality of life measures parable effect to systemic routes and were simple, safe, painless and cost-
have recently been included in assessment of effective therapeutic options.
surgical outcomes. Principal findings: Clinically
significant effects of local and systemic steroid on
post-operative sequelae as compared to control.
Practical implications: Providing good
post-operative course after oral surgery by
simple and available method.

pain, swelling and trismus1–3. Being predictable, these

Introduction
Surgical removal of impacted third molars is a common
practice for oral and maxillofacial surgeons and usually
involves surgical trauma in a highly vascularised area,
predominantly constituted by loose connective tissue,
leading to expected inflammatory complications, also
termed sequelae because they occur often and include
post-operative sequelae can be used for assessing
the efficacy of a variety of pharmaco-therapeutic
measures4.
Quality of life (QOL) is a term that has become
widely applied to many fields in health care – including
dental practice. Many studies used custom question-
naires consisting of several dimensions considered rel-

200 Oral Surgery 6 (2013) 200–208.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Majid & Mahmood
evant to third molar removal5–12. The contemporary
view is that post-operative sequelae after third molar
surgery influence the patients’ QOL in the immediate
post-operative period5,8,10. However, only few studies
have reported on the effect of the different therapeutic
agents that can be used perioperatively on patients’
QOL after third molar surgery13,14.
Perioperative use of corticosteroids is a pharmaco-
logical approach often used for reduction of oedema,
trismus and pain after removal of impacted lower third
molars15–17. Corticosteroids act by inhibiting, through a
variety of proposed mechanisms, the body’s inflam-
matory response to injury, with a reduction of fluid
transudation and therefore oedema15. The use of corti-
costeroids has gained wide acceptance in the oral and
maxillofacial surgery community. However, the most
variable aspect in the use of corticosteroids in oral
surgery is the appropriate route of administration. Dif-
ferent administration routes have been used for these
drugs in oral surgery and every route has its merits and
drawbacks. Numerous reports are now available sup-
porting the use of systemic corticosteroids18–21 while
others have recently concerned with the local admin-
istration of corticosteroids in the setting of third molar
surgery13,22. The difference between various routes
remains to be determined.
The aim of this randomised prospective study was to
compare the effect of dexamethasone in five different
routes of administration on swelling, pain, trismus and
QOL measures for patients in the early post-operative
period after surgical extraction of impacted lower third
molars.
Patients and methods
Study design and sample
A randomised non-blind prospective study was con-
ducted at the Department of Oral and Maxillofacial
Surgery, College of Dentistry, University of Mosul, and
included patients who required surgical removal of a
single impacted mandibular third molar under local
anaesthesia. Patients were randomly divided into six
groups: five treatment groups, in which dexametha-
sone 4 mg was given by five different routes, and one
control group. Randomisation was achieved using a
random numbers table. Neither the patients nor the
surgeons were blinded to the use of corticosteroids. The
study was approved by the local academic committee
according to relevant guidelines.
In order to obtain a study power of 80% at a level of
significance equal to 0.05 using a 2-tailed test, a sample
size of 10.26 units per group was found necessary to
Oral Surgery 6 (2013) 200–208.
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dexamethasone in oral surgery
evaluate the differences among the six study groups. To
improve the power of study and enhance its internal
validity, a sample size of 12 patients per group was
planned for the present clinical trial. This number was
estimated to fit a statistical model for analysing the dif-
ferences among all study groups, the active and con-
trols, together.
Inclusion criteria included partial bony impacted
mandibular third molars with Class II or III and position
A, B or C, according to Pell and Gregory classification
on a radiograph23. All patients were 18 years of age or
older, free of pericoronitis and infection at the time of
surgery.
Exclusion criteria included history of compromised
medical status, history of allergy or hypersensitivity to
the drugs used in this trial, chronic use of any medica-
tion, pregnant or lactating females and patients refused
being involved in the study or those who could not
attend the follow-up visits or those who used non-trial
drugs during the observation period.
All relevant demographic information along with
measurements of mouth opening, cheek flexibility and
body weight and height were recorded in a case form
for each patient. Cheek flexibility was defined as the
distance (mm) between the maxillary dental midline
and the cheek retractor during retraction24. Radio-
graphic examination included digital panoramic radio-
graphs taken for all patients prior to operation to
identify the radiographic features related to the
impacted third molar using an original apparatus
(Dimax3 Ceph, Planmeca OY, Finland). All patients
were informed that they would be enrolled in the study
and a brief overview regarding the steps of surgery,
medications and the required follow-up was given to
them. Each patient provided an informed consent to
participate in the study.
Surgical procedure
A standardised surgical procedure was performed on all
patients by the same right-handed operator in the same
operating room and under similar conditions. A stand-
ard inferior alveolar and long buccal nerve block was
given using 1.8 mL cartridges of 2% lidocaine hydro-
chloride with epinephrine 1:100 000. Surgical access
routinely achieved buccally through a triangular full
thickness flap. Bone removal around the tooth was
then performed with a round bur on a straight hand
piece under continuous irrigation with a diluted chlo-
rhexidine solution. After extraction, the socket was
inspected, copiously irrigated, excess follicular tissue
removed if present, and the flap was returned to its
original position, sutured back by two interrupted
201
Dexamethasone in oral surgery
stitches using a 3-0 silk suture one of them placed just
distal to the lower second molar and the other one
placed distally. A small gauze pack was then applied on
the surgical site, and the usual post-extraction instruc-
tions were given. Duration of surgery in minutes (from
initial incision to the last suture) was recorded.
Post-operative medications
Patients were randomly divided into six groups, with
12 patients in each. The five treatment groups received
4 mg dexamethasone (Dexa-Allvoran®, TAD Pharma
GmbH, Legmo, Germany) as submucosal, intramuscu-
lar and intravenous injection; and as oral tablets and
endoalveolar application of dexamethasone powder
(Dekort®, Deva Holding A, Turkey), respectively. All
injections were given immediately after surgery. Sub-
mucosal dexamethasone was injected into the buccal
vestibule near the surgical site, while intramuscular
injection was given in the deltoid muscle, and the
intravenous dexamethasone was injected through the
veins of forearm. Oral tablets were taken as four doses
of 1 mg every 6 h in the first post-operative day.
Endoalveolar dexamethasone was applied incremen-
tally into the extraction socket using a small plastic
spoon with a long handle, followed by careful packing
to avoid spreading of the powder before suturing the
wound edges onto it. In the sixth group (control),
patients received no corticosteroid treatment.
In addition, all patients in the study routinely
received amoxicillin (oral 500 mg every 8 h) for 5 days
following surgery and tramadol tablets (oral 50 mg on
need) as a rescue analgesic. A chlorhexidine mouth
rinse was prescribed twice daily to be started the day
after surgery and for 5 days.
Assessment and follow-up
Each patient was seen and assessed at the first, third
and seventh post-operative days by an independent
examiner who was already familiarised to evaluate
different study parameters. Facial pain, swelling and
trismus were measured. Post-operative pain was
evaluated using a visual analogue scale (VAS), 10 cm in
length, ranging from 0 = ‘no pain’ to 10 = ‘the worst
possible pain’. Patients were also instructed to report
the number of rescue analgesic tablets required on the
day of surgery (6 h post-operatively) and on each sub-
sequent day of follow-up for the first post-operative
week.
Facial swelling in the operation side was evaluated
by assessing three facial measurements using flexible
length measuring tape25: Tragus-midline (pogonion),
202
Majid & Mahmood
tragus-canthus of mouth and gonion-lateral canthus.
The arithmetic mean of these measurements was taken
as the final estimate of swelling. The preoperative
values (in millimetres) were taken as the baseline for
that side.
Trismus was measured as the difference in inter-
incisal distance (in millimetres) at maximum mouth
opening. Again, preoperative measures were consid-
ered as baseline.
To measure the effect of surgery on QOL, a modified
questionnaire was used to evaluate quality of life after
third molar extraction. The clinical validity of this
questionnaire was demonstrated in a previous study by
its ability to discriminate between different groups of
patients and its good correlation with the objectively
measured variables14. The questionnaire involved dif-
ferent items addressing social isolation, working isola-
tion, eating ability and diet variations, speaking ability,
sleep impairment and physical appearance. After
giving a simple overview about these items, each
patient received the questionnaire to be filled on day 4
after surgery and returned at the time of suture
removal by day 7. They were instructed to answer the
questions and rate on a 4-point scale (never to very
much) their experience of third molar surgery. The
total score range is (0 - 42). The questionnaire also
included questions about the duration of effect on each
element of QOL to be recorded by patients on day 7.
Statistical analysis
Data were processed using the Statistical Package for
Social Sciences, version 12 (SPSS, Chicago, IL). A
descriptive analysis of each variable under study was
made. Demographic and clinical characteristics of
the patients were analysed by analysis of variance
(ANOVA) or Pearson chi-square (c2) test, as appropri-
ate. ANOVA was also used to compare QOL scores
and duration of effect among different groups. Post
hoc analyses were performed by Duncan’s test.
P-values < 0.05 were considered significant.
Results
Demographic data
A total of 72 patients were included in the study
and completed the questionnaire and measurements.
There were no missing data, and the patients included
in this study attended all the study visits. The mean age
of patients in total (32 males and 40 females) was 25.6
(⫾ 5.9) with a range of (18–48). Data about demo-
graphic and clinical characteristics of patients and
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© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Majid & Mahmood Dexamethasone in oral surgery

Table 1 Demographic and clinical characteristics of the patients in study groups

Variable Control Intramuscular Submucosal Oral Intravenous Endoalveolar Total P-value

Age (years) 23.5 (4.2) 30 (9) 23.7 (4.6) 25.4 (3.6) 25 (2.7) 24 (3.3) 25.5 (5.8) 0.041†
Gender
Male 4 8 4 4 8 3 32 0.137‡
Female 8 4 7 8 4 9 40
Smoking
Yes 1 3 1 0 2 2 9 0.532‡
No 11 9 11 12 10 10 63
BMI (kg/m2) 24 (2.2) 28.7 (3.7) 23.5 (3) 24.7 (2.7) 24.6 (3) 23.3 (6) 24.8 (4) 0.054†
Difficulty score 6.4 (0.9) 6.7 (0.7) 7 (1.1) 6.1 (0.6) 6.3 (0.5) 6.3 (0.6) 6.4 (0.8) 0.351†
IID (mm) 46.1 (5.7) 44.6 (4.8) 45.6 (4.6) 44.4 (3.7) 47.3 (7.9) 43.7 (7.6) 45.3 (5.8) 0.724†
Cheek flexibility (mm) 47.4 (5) 48.7 (4.7) 52.5 (4.4) 45 (5) 48.8 (6.5) 45 (2.8) 48 (53) 0.125†
Duration (minutes) 36.5 (8.5) 42.5 (13) 31 (9.6) 31 (4.5) 29.5 (5) 34.6 (4.3) 35.7 (9.3) 0.064†

Data are presented as mean (standard deviation) or as number.

†
Analysis of variance (ANOVA).
‡
Chi square (c2) test.
BMI, body mass index; IID, inter-incisal distance.

14

13.5
Control

Swelling (mm)
IM 13
SM
12.5
Oral
IV 12
EA
11.5

11
Pre Day 1 Day 3 Day 7

Figure 2 Profile mean of swelling measurements at follow-up check

points of study groups. IM, intramuscular; SM, submucosal; IV, intrave-
Figure 1 Distribution (by number and percentage) of tooth angulation in nous; EA, endoalveolar.
study sample.

50
45
Inter-incisal distance (mm)

duration of surgery in each study group are listed in Control

40
Table 1. There were no statistically significant differ- 35
IM
30
ences in these variables among study groups except for SM
25
age variable which were significantly older in intra- Oral
20
muscular group only as compared with other groups. IV
15
EA
The predominant position according to the Pell and 10
5
Gregory classification was IIA (48%), followed by IIB
0
(39%) and IIC (13%). The most common tooth angu- Pre Day 1 Day 3 Day 7
lation was the mesioangular (38%), and the least
common was the distoangular (13%) (Fig. 1). Figure 3 Profile mean of mouth opening at follow-up check points of
study groups. IM, intramuscular; SM, submucosal; IV, intravenous; EA,
endoalveolar.
Profile of measurements within groups
In all groups, swelling and trismus were most severe on
the first post-operative day and decreased gradually measurements on day 1 were only significant in the
through the subsequent evaluation points to reach control group when compared to preoperative meas-
approximately preoperative measures by the seventh urements. In all dexamethasone treated groups, swell-
day (Figs 2 and 3). However, differences in swelling ing at this interval showed no significant changes.

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© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dexamethasone in oral surgery
7 routes in a descending order. This effect was accordingly
6 reflected on the total number of rescue analgesic tablets
Control
5
IM
Pain (VAS)
SM 4
Oral 3 Effect on QOL
IV
2
EA
1
0 scores (P < 0.01) as compared with the control group
Day 1 Day 3 Day 7
Figure 4 Profile mean of pain measurements at follow-up check points of
study groups. IM, intramuscular; SM, submucosal; IV, intravenous; EA,
endoalveolar, VAS, visual analog scale.
Trismus, on the other hand, was significantly worsened
at the same interval in all groups. Pain (on VAS) also
reached its peak on day 1 and faded away by day 7
(Fig. 4). The latter effect was reflected on the number of
rescue analgesic taken at each interval, which showed
significantly higher counts on day 1 after surgery
except in the control group where patients reported
more analgesic consumption during the second and
third post-operative days (Table 2).
Profile of measurements among groups
All dexamethasone treated groups showed statistically
significant differences in the magnitude of swelling and
pain mostly at all intervals (P < 0.05) when compared
with the control group (Table 2). Similarly, the total
number of rescue analgesic tablets taken on each
interval was significantly lower in dexamethasone
groups except for the oral group compared to controls.
No patient continued pain medication beyond day 5.
Regarding trismus, all dexamethasone groups showed
significant improvement on day 1 and 3 as compared
with the control group (P < 0.05).
Considering dexamethasone treatments, there were
no significant differences among groups for all param-
eters. However, as long as swelling is considered, intra-
venous route gave the best improvement, followed by
intramuscular, submucosal, oral and endoalveolar
routes in a descending order on the first post-operative
day. Interestingly, the endoalveolar group showed
better improvement on day 3. The effect on trismus was
comparable among treatment groups with an advantage
to submucosal route especially on day 1. Again, endoal-
veolar dexamethasone showed better effect on trismus
at the subsequent intervals, that is, day 3 and day 7. With
respect to pain (on VAS), intravenous dexamethasone
continued to be the best at all intervals, followed by
endoalveolar, submucosal, oral and intramuscular
204
Majid & Mahmood
taken by the patients.
All dexamethasone groups showed highly significant
differences regarding the effect on QOL in all subscale
(Table 3). The difference was also significant for the total
duration of effect on QOL among the groups. However,
the effect was comparable among the treatment groups
in all parameters. Intravenous group showed the lowest
scores followed by submucosal group.
When the duration of effect on QOL was compared,
patients in the control group revealed impairment in
their life activities, represented by the total QOL score,
for an average of 2.8 days (range 2–4) after surgery. On
the other hand, the average duration of impaired QOL
in the treatment groups was 1.2 days (range 0–2) post-
operatively (Table 4). The duration was significantly
shorter in the treatment groups as compared to controls
for all subscales except for ‘sleep’ score. In total, the
shortest impairment reported by patients was in the
intravenous group followed by oral and submucosal
groups in an ascending order.
Complications
Up to the end of follow up period, no cases of alveolar
osteitis or wound infection were reported. Only two
patients reported lip paraesthesia which was resolved
in both by the seventh post-operative day. No side
effects of drugs used in the trial were mentioned or
noted.
Discussion
Study design and methodology
The present study was designed to be a randomised
controlled clinical trial. Because it had to be conducted
to measure the effect of different routes of administra-
tion, it was unfeasible to make it a blind trial, especially
from side of the patients. However, randomisation in
allocation of treatment on groups was planned to
overcome this possible bias. In addition, most variables
were assessed objectively, which ultimately reduced
the effect of potential patient-related bias.
Regarding endoalveolar application of dexametha-
sone, there is a potential that some powder might be
inadvertently lost during manipulation, but this seems
insignificant and its potential is equal for all cases.
Oral Surgery 6 (2013) 200–208.
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Majid & Mahmood Dexamethasone in oral surgery

Table 2 Swelling, pain, and trismus measurements among study groups

Variable Control Intramuscular Submucosal Oral Intravenous Endoalveolar P-value †

Swelling (Cm) ‡
Day 1 5.2 (0.8) 1.2 (1.1)* 1.5 (0.6)* 2.2 (0.8)* 0.9 (0.3)* 2.3 (0.9)* <0.01
Day 3 3.5 (0.9) 0.7 (0.6)* 1.2 (0.5)* 1.7 (0.4)* 0.2 (0.1)* 0.5 (0.2)* <0.01
Day 7 0.7 (0.4) 0.1 (0.2)* 0.1 (0.1)* 0.5 (0.3) 0* 0.1 (0.01)* <0.01
Pain (VAS)
Day 1 7.0 (2) 3.2 (3)* 2.9 (2.7)* 3.0 (2.6)* 1.3 (1)* 1.4 (1.1)* 0.002
Day 3 4.5 (2.1) 1.1 (2)* 1.4 (2.3)* 1.7 (1.6)* 0.2 (0.2)* 0.5 (0.9)* 0.002
Day 7 1.6 (2.5) 0.2 (0.6)* 0.2 (0.6)* 0.2 (0.3)* 0* 0* 0.02
Trismus (mm) ‡
Day 1 22.9 (8.8) 14 (9)* 11.5 (9)* 13 (7)* 13 (9)* 14.4 (8)* 0.016
Day 3 17.8 (11) 10 (8.4)* 8.6 (8.4)* 8 (3.6)* 8.2 (5)* 7.8 (3.5)* 0.005
Day 7 11.3 (9) 4.8 (4.2)* 5.2 (7)* 4 (3)* 4.5 (3)* 3.3 (3)* 0.021
No. of tablets 3.75 (3) 2.2 (2.1)* 1.6 (1.4)* 2.7 (2) 1.2 (0.8)* 0.75 (0.6)* <0.01

Data presented as mean (standard deviation).

*Significantly different compared with control (P < 0.05).
†
Analysis of variance (ANOVA).
‡
Measured as the difference from preoperative measurements.

Table 3 Comparison of QOL subscales among study groups

Control Intramuscular Submucosal Oral Intravenous Endoalveolar P value †

Social 1 (0) 0.25 (0.1)* 0.5 (0.3)* 0.4 (0.2)* 0.3 (0.1)* 0.5 (0.1)* <0.001
Eating 9.5 (2.7) 7.1 (3.4)* 4.8 (2.2)* 5.1 (3)* 4.7 (2.2)* 5.3 (2.3)* <0.001
Speech 3.5 (2.5) 1.7 (2)* 1.1 (1.7)* 0.5 (0.8)* 0.9 (1.2)* 0.6 (0.9)* <0.001
Sleep 2.7 (1.7) 0.8 (1.2)* 0.8 (1.3)* 0.8 (0.8)* 0.75 (1.5)* 0.75 (0.7)* 0.002
Appearance 2.3 (0.9) 0.8 (1.1)* 1 (0.7)* 0.5 (0.6)* 0.3 (0.4)* 0.7 (0.6)* <0.001
Total 19 (2) 9.5 (2.5)* 8.4 (3.1)* 9.2 (3.2)* 7.8 (4.2)* 9.4 (3)* <0.001

Data presented as mean (standard deviation).

*Significantly different compared with control (P < 0.05).
†
ANOVA.

Table 4 Comparison of duration (in days) of effect on QOL among study groups

Control Intramuscular Submucosal Oral Intravenous Endoalveolar P value †

Social 3 (0.7) 0.5 (0.9)* 0.8 (0.9)* 0.8 (0.9)* 0.8 (1.2)* 1.3 (1.2)* <0.001
Eating 3.5 (0.5) 2.5 (1)* 2 (1.2)* 2.4 (1)* 2.3 (1.2)* 2.4 (1)* 0.028
Speech 2.3 (1.7) 1.3 (1.5) 0.4 (0.5)* 0.5 (0.8)* 1 (1.2)* 0.6 (0.9)* 0.003
Sleep 1.7 (1.2) 0.75 (1) 0.7 (0.7)* 0.9 (0.9) 0.6 (1.1)* 1.25 (1.4) 0.146
Appearance 3.5 (0.9) 1.3 (1.4)* 2 (1.4) 1 (1.5)* 0.6 (1.1)* 1.3 (1.4) <0.001
Total 2.8 (1.5) 1.27 (1) 1.18 (0.7)* 1.1 (0.7)* 1.06 (1.2)* 1.37 (1.1) 0.004

Data presented as mean (standard deviation).

*Significantly different compared with control (P < 0.05).
†
ANOVA.

Using some carriers to apply the drug may solve this
procedural problem and should be considered in future
studies.
Swelling was evaluated by measuring linear facial
distances: a non-invasive, simple, cost-effective and
time-saving method, which provides numeric data for
determination of soft-tissue changes. In addition, this
method was reported in many previous studies21,25,26.
Methods used for measuring trismus and pain are also
universally accepted which enables making a logical
comparison among different studies.
Post-operative sequelae in the control cases
The profile changes in swelling, pain and trismus in the
control group were classical to those reported in the

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© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dexamethasone in oral surgery
literature3,27,28. Every one of these variables reached its
peak on day 1 post-operatively and then reduced
gradually on subsequent visits to reach values close –
but not equal – to preoperative (baseline) measures.
Similarly, third molar surgery was associated with a
deterioration of QOL in the immediate post-operative
period, a finding which also comes to agree with the
literature5,6,8–10,12.
Dose and timing of dexamethasone treatment
There were multiple studies that evaluated the effec-
tiveness of dexamethasone in third molar surgery
using different routes with variable results13,17,19,22,29–31.
This variability may be related to the lack of consen-
sus about the optimal route of administration, dose,
timing and duration of therapy, in addition to differ-
ences in methodology used for evaluation of clinical
parameters.
The effect of dexamethasone on swelling, pain and
trismus after third molar surgery seems to be dose
dependent30. Some authors suggested that 4 mg is a
subtherapeutic dose15. However, Grossi et al.13 reported
an equivalent effect of 4 mg and 8 mg doses of submu-
cosal dexamethasone. Therefore, the smaller dose
(4 mg) was used in the present study.
Corticosteroid therapy may not be necessary in all
wisdom tooth removals but indicated only in cases of
some technical difficulty18,32. Giving dexamethasone
post-operatively in the current study offers data about
its effect at this timing so that surgeons would be able to
use dexamethasone in moderate and difficult cases
according to post-operative measures of surgical diffi-
culty, depending on the duration and circumstances of
operation.
Systemic dexamethasone
Regarding the effect on swelling and pain, intravenous
and intramuscular dexamethasone showed better
improvement as compared with the oral route,
although the differences among the three groups were
not significant. This was expected as parenteral routes
provide quicker effect with less amount of the drug
being lost. However, the effect of oral dexamethasone
on trismus was somewhat better than the parenteral
routes; a finding that may be related to the extended
time over which the drug was delivered in the oral
group, in spite of that the same dose was given. After
extensive review of the literature, we could not find
any clinical trial evaluating the effect of different sys-
temic routes together; therefore, no comparison can be
made here in this regard.
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Majid & Mahmood
Locally applied dexamethasone
In the present study, submucosal dexamethasone
showed a significant reduction of swelling on all post-
operative intervals as compared with the controls,
which comes in agreement with the previous stud-
ies13,22. These results add more strength to the concept
that locally applied dexamethasone near surgical site in
a subtherapeutic dose (4 mg) is a valuable tool to
reduce oedema after performing moderate to moder-
ately severe impaction surgery. However, unlike pre-
vious studies that reported only a limited effect on
trismus and pain, our patients showed significantly less
trismus and pain at all times of evaluation in the sub-
mucosal group as compared with controls. Different
methodology of pain assessment and different timing of
injection in the previous studies13,22 may be the causes
of this disagreement33.
Regarding endoalveolar application of dexametha-
sone, the present study showed a significant reduction
in all parameters as compared with controls, which is
parallel to findings of Graziani et al. study22 regarding
swelling and trismus but not pain. These authors found
that endoalveolar application of 4 mg dexamethasone
powder resulted in lower pain perception than 10 mg
powder concentration, a finding which they could not
explained.
An interesting finding of the present study appeared
when the two local routes of administrations were
compared. Submucosal dexamethasone showed better,
but yet not significant, reduction of swelling and
trismus on day 1 interval than endoalveolar dexam-
ethasone, which is turned to show a better effect on the
subsequent times. Similarly, endoalveolar dexametha-
sone was associated with less pain scores and rescue
tablets than submucosal one at all intervals. The pro-
longed time at which dexamethasone stays in contact
with the tissues may stand behind this observation.
Submucosal injection may provide an initial faster rate
of absorption, while endoalveolar application provides
a more extended contact with the tissues offering more
profound effect after day 1.
Systemic versus local dexamethasone
Effect on post-operative sequelae
We have recently reported a comparable effect for
submucosal dexamethasone to intramuscular one on
post-operative sequelae and quality of life after third
molar surgery14,33. Before that, and up to our best
knowledge, no studies were available that compare
local with systemic routes. In the present study, all
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Majid & Mahmood
dexamethasone groups showed a significant reduc-
tion in swelling, pain and trismus during the first
post-operative week when compared to controls.
Moreover, local application of dexamethasone
showed more swelling reduction, though not signifi-
cant, than the oral route, but exhibited less effect than
intravenous and intramuscular routes. Regarding
pain, both types of local application also showed
better results than oral and intramuscular routes. The
effect on trismus showed better results on day 1 and
on subsequent intervals for submucosal and endoal-
veolar routes, respectively than both oral and intra-
muscular routes.
Effect on QOL
In the present study, all treatment groups showed sta-
tistically significant differences in all subscales of QOL
questionnaire during the immediate post-operative
period as compared to controls, while the results were
comparable among treatment groups with more ben-
eficial effect for the intravenous route in most sub-
scales, giving a profile that follows the objectively
measured effects of different routes on post-operative
sequelae. This disagrees with previous studies13,20. In
Grossi et al. study13, timing of injection (preoperatively)
and taking the QOL measurement after 1 week may
have reduced the total effect. It could well be that the
patient scoring was biased downwards because it was
recorded when the effect of third molar surgery had
diminished to quite an extent. On the other side, sur-
gical extractions in Tiwana et al. study20 were per-
formed under general anaesthesia which might affect
many aspects of QOL recovery.
Routine use of antibiotics may be the cause behind
the absence of infection in this study. Although there
are some arguments against this protocol worldwide, it
is still applied in Iraqi maxillofacial surgery centres,
which may be related to cultural and social factors. It is
a point that may require further research.
Overall, the comparable results obtained among
treatment groups indicate the advantage of local dex-
amethasone as an effective alternative to systemically
applied one. Local dexamethasone is quite simple,
safe, less invasive, painless and cost-effective solution
for the typical patient’s discomfort associated with the
surgical removal of impacted lower third molars. As
this route offers a comparable therapeutic option to
the systemic one, dentists and oral surgeons can
determine for themselves their competence to admin-
ister steroids by a particular route. Post-operative
administration offers the advantage of concentrating
the drug near the surgical area with less systemic
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Dexamethasone in oral surgery
absorption and without further surgical manipulation
of tissues. This timing also allows the surgeon to
accurately assess the need for steroid injection
according to post-operatively recorded surgical diffi-
culty and duration of intervention.
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