The Impact of Prior Use of

Corticosteroid to Dental Extraction on

Oral Health-Related Quality-of-Life and
Clinical Outcomes: A Randomized
Clinical Trial
Heitor B. Pansard, MD,* Mayara C. Prado, MD,y Gabriel F. Marchi, DDS,z
Camila S. Sfreddo, PhD,x and Jovito A. Skupien, PhDk
Purpose: To evaluate the impact of prior use of corticosteroids before dental extractions on oral health–
related quality-of-life (OHRQoL).
Methods: A randomized and triple-blind (patient, surgeon, and examiner) clinical trial was designed.
The individuals were randomly allocated to 2 groups: test and placebo. In the test group, 2 capsules of
4 mg dexamethasone were administered orally. In the placebo group, subjects received 2 capsules with
the same characteristics. In both groups, the administration took place 1 hour before the procedure. OHR-
QoL was assessed by the Brazilian version of Oral Health Impact Profile 14 (OHIP-14). The OHIP-14 ques-
tionnaire and the assessment methods for clinical parameters were collected preoperatively and
postoperatively. Multilevel linear regression models fitted the associations between preoperative use of
corticosteroids and overall and domain-specific OHIP-14 scores over time.
Results: One hundred fourteen patients were selected for the study; however, 21 were excluded for not
returning to postoperative control on the seventh day, resulting in 93 patients assessed (test = 44 and pla-
cebo = 49). The pain had a negative impact on OHRQoL (P < .01); however, the use of the drug had no
statistically significant influence on OHRQoL (P = .62) and the clinical outcomes of pain (P = .63), mouth
aperture (P = .05), and edema (P = .69).
Conclusions: The use of the 8 mg dexamethasone administered orally before the procedure was not
effective on the improvement of the quality-of-life of patients undergoing dental extraction. However, us-
ing the medication seems to result in an improvement in the postoperative period of patients who had
impacted teeth. Further research involving the analysis of OHRQoL must be performed, and other dosages
and means of administration must be tested.
Ó 2020 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 78:2153.e1-2153.e9, 2020

*MD Student, Health and Life Sciences Master’s Student by the
Franciscan University (UFN), Santa Maria, RS, Brazil.
yMD Student, Health and Life Sciences Master’s Student by the
Franciscan University (UFN), Santa Maria, RS, Brazil.
zPrivate Practitioner, Specialist in Bucco Maxillofacial Surgery
and Traumatology, Santa Maria, RS, Brazil.
xProfessor, Dental School Professor of the Franciscan University
(UFN), Santa Maria, RS, Brazil.
kDepartment Head, Health and Life Sciences Master’s and Dental
School of the Franciscan University (UFN), Santa Maria, RS, Brazil.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Skupien:
Franciscan University, Health and Life Sciences Master’s and Dental
School, Rua dos Andradas 1614, 97010-032, Santa Maria, RS, Brazil;
e-mail: skupien.ja@gmail.com
Received May 22 2020
Accepted August 11 2020
Ó 2020 American Association of Oral and Maxillofacial Surgeons
0278-2391/20/31058-2
https://doi.org/10.1016/j.joms.2020.08.013

2153.e1
2153.e2 DENTAL EXTRACTION ON ORAL HEALTH-RELATED QUALITY-OF-LIFE AND CLINICAL OUTCOMES
Dental extractions performed under local anesthesia,
especially of third molars, are routinely performed in
dental clinics and specialized ambulatory clinics, tak-
ing up a considerable amount of clinical time. This sur-
gical procedure generates a trauma that results in
direct and immediate consequences, such as postoper-
ative pain, edema, and trismus.1,2 These adverse ef-
fects of dental surgery may be related to a worsening
in the quality-of-life of individuals.3
The surgical healing process resulting from dental
extractions occurs in different phases initiated by a
series of inflammatory events. The inflammatory
phase is responsible for the postoperative signs and
symptoms, which start at the moment of the trauma
and normally lasts between 3 and 5 days.4 Symptoms
of pain and edema peak on the first and second days
after the trauma and are usually resolved on the sev-
enth day.1
Corticosteroids have been used as a promising strat-
egy in the postoperative control of the edema, pain,
and trismus after the treatment of dental extrac-
tions.5,6 Corticosteroids act in several stages of the in-
flammatory chain, inhibiting vascular dilation,
reducing liquid transudation and edema formation,
decreasing cell migration, and reducing the deposits
of fibrin around the inflammation area.7 The use of
dexamethasone injected in the surgical region showed
a significant improvement in swelling, pain, trismus,
and different dimensions of health-related quality-of-
life after surgical removal of the impacted lower mo-
lars.8 Similarly, the results of a meta-analysis suggest
that the administration of corticosteroids in patients
undergoing extractions has a mild to moderate effect
in reducing inflammatory symptoms up to 7 days after
surgery.9 These results also indicate an edema and
trismus reduction compared with controls after sur-
gery. However, the authors emphasize the need for
further large-scale prospective investigations to
adequately assess the ideal type and dosage of cortico-
steroids, as well as the appropriate administration of
the time, mainly related to the decrease of negative im-
pacts on the oral health–related quality-of-
life (OHRQoL).9
The OHRQoL is a multidimensional construct used
to measure the impact of oral conditions and oral func-
tions, on the physical-social level, on appearance and
social functions and, consequently, the impact on
the performance of daily activities and self-
perception of oral health.10 The postoperative period
of dental extractions and how much they impact on
the OHRQoL of individuals have been evaluated by au-
thors such as Beech et al.11 as well as Ibikunle and
Adeyemo,2 who have found a better OHRQoL in pa-
tients who used cryotherapy in the postoperative
period. In addition, Hanna et al12 have used Twitter
as a means to research and analyze the impact of third
molar extractions on OHRQoL, demonstrating it as a
good tool to obtain real-time quality-of-life data.
A complete understanding of the postoperative
complications of this procedure allows the profes-
sional to identify and advise patients, properly manage
the most common complications, and use the most
effective treatment methods, so that the signs and
symptoms are kept to a minimum, without interfering
on the patients’13 daily activities and, consequently,
negatively impacting on the OHRQoL. Thus, this ran-
domized clinical trial has the main objective to eval-
uate the prior use of corticoids to dental extractions
on the OHRQoL in adults. In addition, this study
analyzed the influence of corticosteroids on clinical
outcomes. We hypothesized that the preoperative
use of corticosteroids positively impacts OHRQoL
in adults.
Materials and Methods
The researchers followed the recommendations for
the report of clinical trials based on the Consolidated
Standards of Reporting Trials14 statements.
ETHICAL ASPECTS
This research was designed based on the 466/2012
norm. Before the beginning of the research, the proj-
ect was submitted and approved in accordance with
the opinion number: 3.105.400, issued by the commit-
tee on ethics in research of the Universidade
Franciscana.
DESIGN
This study was a randomized and triple-blind (pa-
tient, dental surgeon, and examiner) clinical trial,
with groups in parallel, carried out at the Bucco Maxil-
lofacial Surgery and Traumatology Service of Casa de
Sa
ude—Hospital of Santa Maria—RS, reference of the
fourth coordinator office of Rio Grande do Sul state
by the Unified Health System, with an average of about
200 patients seen per month.
PARTICIPANTS
All individuals who attended the Bucco Maxillofacial
Surgery and Traumatology Service for teeth extraction,
between the months of February and December of
2019, were invited to participate in the study. All
eligible individuals took part in the study and, after
reading an informed consent form, agreed to partici-
pate and signed the document.
The inclusion criteria included classification by
American Society of Anesthesiologists 1 (healthy indi-
viduals, without systemic disease and continuous
medication); older than 18 years old; both sexes; the
absence of pericoronitis in the last 30 days; and no
PANSARD ET AL
sign of inflammation. The exclusion criteria included:
refused to participate after reading the informed con-
sent form, incorrect indication of tooth extraction, al-
lergy to any of the study drugs, smokers, pregnant or
lactating women, and use of medication that inter-
acted with the medication used in the study. Thus, a to-
tal of 114 individuals were included in the study.
INTERVENTIONS
The surgical procedures strictly followed surgical
biosafety criteria. The surgery involved tooth extrac-
tion under local anesthesia with 2% mepivacaine hy-
drochloride with epinephrine 1:100,000. When
necessary, an incision, a periosteal detachment, and
osteotomies were performed to facilitate tooth
removal, in addition to meticulous irrigation of the sur-
gical site with 0.9% of saline solution. The surgical
wound was sutured with 3 to 015 Mononylon (Ethicon,
Johnson & Johnson, Somerville, New Jersey). Before
the surgery, patients in the test group received 2 tab-
lets of 4 mg dexamethasone orally 1 hour before the
start of the surgical procedure, whereas those in the
control group received 2 placebo tablets that were
administered in the same way as to the test group.
After the procedure, both groups received a written
prescription for analgesic (750 mg of paracetamol
administered orally, 1 unit every 6 hours as needed
for pain), anti-inflammatory (100 mg of nimesulide
administered orally, 1 unit every 12 hours for
4 days), antibiotic (500 mg of amoxicillin administered
orally, 1 unit every 8 hours for 7 days), and mouthwash
(0.12% of chlorhexidine digluconate without alcohol
to rinse from the second day, twice a day, for 1 minute,
for 7 days).15 Patients were instructed to eat only light
and cold foods and to refrain from mouthwash during
the first 24 hours. In addition, they were instructed not
to brush or floss around the surgical area until the su-
ture was removed. Patients were requested by proto-
col to return for follow-up in 7 days. To avoid
observer bias, all postoperative data were recorded
by the same evaluator.16
INDEPENDENT VARIABLES AND OUTCOMES
A preoperative clinical record was performed where
the following information was collected: age, sex, oral
condition, and general health.17 Clinical and radio-
graphic examinations were used to diagnose the
need for extractions, according to the relevant litera-
ture.15 Eligible individuals were divided and random-
ized into 2 groups: the test group and the
placebo group.
The OHRQoL was assessed using the Brazilian
version of Oral Health Impact Profile 14 (OHIP-14)
questionnaire and was considered the primary
outcome of this study. The OHIP-14 was applied in a
2153.e3
face-to-face interview by a trained researcher, before
the surgical procedure and 7 days after the operation.
In addition, the questionnaire was self-administered
on the first and third postoperative days. On the sev-
enth postoperative day, it was completed after the su-
ture was removed, whereas on the first and third days,
they were instructed to complete it at 8 PM. The OHIP-
14 questionnaire has 14 questions that assess 7 do-
mains: functional limitation, physical pain, psycholog-
ical discomfort, physical disability, psychological
disability, social disability, and handicap.10 Each ques-
tion has 4 answer options on a scale ranging from
0 to 4: never (code 0); rarely (code 1); sometimes
(code 2); repeatedly (code 3); and always (code 4).
OHIP-14 scores were obtained by the sum of all scores
by domain and the total score ranging from 0 to 56.
High OHIP-14 scores indicate a worse OHRQoL. Sec-
ondary outcomes were clinical parameters, such as
edema, mouth aperture, and pain. During the first
dental appointment, clinical measures were per-
formed with a 3 to 0 silk thread and a millimeter ruler.
Linear measurements were made between the angle of
the mandible and the following points for measuring
facial edema: tragus, the wing of the nose, outer corner
of the eye, labial commissure, and chin.18
The mouth aperture was evaluated by measuring
the distance between the incisal edges of the upper
and lower central incisors on the right side at
maximum aperture. Measurements were performed
before the surgery and on the seventh postopera-
tive day. For pain measurement, each participant
received a postoperative evaluation form with
3 visual analog scales; this scale was used in the
form of a ruler with one edge representing the
absence of pain (0) and the other representing un-
bearable pain (10). The patient was requested to
check the intensity of the pain on this scale at 8
PM on the first postoperative day, third postopera-
tive day, and after the removal of the suture on
the seventh postoperative day. The visual analog
scale questionnaires and scales were collected by
the research team on the seventh day. All clinical
evaluations and surgical procedures were per-
formed by dental surgeons who have more than
8 years of experience as specialists.
SAMPLE CALCULATION
The sample size was calculated based on a 5% signif-
icance level, 80% study power, percentage of individ-
uals with an impact on the OHRQoL after 7
postoperative days of 16.1% in the test group (use of
corticosteroids) and 46.1% in the control group.2 A to-
tal of 42 individuals were needed in each experimental
group. Considering a loss rate of 30%, a minimum sam-
ple size of 55 individuals in each group was estimated.
2153.e4 DENTAL EXTRACTION ON ORAL HEALTH-RELATED QUALITY-OF-LIFE AND CLINICAL OUTCOMES

RANDOMIZATION 1) were nested in individuals (level 2). The multilevel

A sequence of random numbers was generated by a
computer, in 3  3 blocks, so that there was no
disparity between the groups. Thus, 5 different se-
quences were performed: upper third molars, upper
impacted third molars, lower third molars, lower
impacted third molars, and septic teeth of the same
quadrant. The sequences were generated by a third
person, who was unrelated to the clinical procedures.
To ensure concealment, the head person noted a num-
ber corresponding to the allocated group on a white
paper, and this was placed in opaque envelopes,
numbered consecutively, which were used in the pa-
tient’s order of arrival.
BLINDNESS
The blinding was triple, where the patient, dental
surgeon, and examiner were blinded concerning the
group. The patients received the medication that
was administered before the surgery in an equal
manner, where it was not possible to know which
type of medication was being used. The drugs had
the same color, appearance, and taste properties so
that it was not known which group the patient was
allocated to. Likewise, the evaluator was also blinded
because only the person responsible for randomiza-
tion knew which group each patient belonged to.
univariate models used the fixed-effects scheme with a
random intercept. The results were presented as a co-
efficient (b) and its respective standard error. A simple
linear regression model was also created to investigate
the effect of variables on the clinical outcomes.
Results
Twenty-one patients were excluded because of not
returning to the ambulatory clinic on the seventh day
for suture removal and the delivery of the question-
naires. Surgeries took no more than 40 minutes, and
no cases of infection were found. Ninety-three patients
from the initial 114 were analyzed, 61 women and 32
men with a mean age of 31.43 (standard deviation,
11.76), with 49 patients in the placebo group and 44
patients in the test group (Fig 1, Table 1).
Table 2 shows the averages of overall and domain-
specific OHIP-14 scores according to the experimental
groups. There were no statistically significant differ-
ences (P > .05) between the OHIP-14 means according
to the groups at the different experimental times.
However, when analyzing the 2 groups in the

STATISTICAL ANALYSIS
The data were analyzed using the Stata program (Sta-
taCorp 2014, Stata statistical software: release 14.1;
StataCorp LP, College Station, TX). Categorical vari-
ables were described through their frequency distribu-
tions and quantitative variables by measures of central
tendency and dispersion. The primary outcome of the
study was considered the longitudinal change in the
OHRQoL. The variable was obtained by the total
scores and domains in the 4 experimental times (pre-
operative, first, third, and seventh postoperative
days). Pain, the secondary outcome, was assessed as
the longitudinal change on the first, third, and seventh
postoperative days. The edema variable was obtained
by adding the 5 linear measurements of the face before
and after the operation. Subsequently, the difference
between the preoperative and postoperative edema
was obtained, and the variable was categorized as
‘‘improved’’ or ‘‘worsened’’. The mouth aperture was
obtained by the difference of the measurement in milli-
meter in the preoperative and postoperative periods
and was categorized as ‘‘improved’’ or ‘‘worsened.
Multilevel models were constructed using linear
regression to assess the impact of preoperative use FIGURE 1. Flowchart of the participants in the randomized clinical
of corticosteroids on changes in the OHRQoL over- trial.
time in the experimental groups. In the multilevel Pansard et al. Dental Extraction on Oral Health-Related Quality-of-
structure, OHIP-14 scores measured over time (level life and Clinical Outcomes. J Oral Maxillofac Surg 2020.
PANSARD ET AL 2153.e5

Table 1. CHARACTERISTICS OF PATIENTS INCLUDED

obtained in the postoperative and preoperative mea-
IN THE CLINICAL TRIAL AND THE OUTCOMES surements (Table 3).
ANALYZED The multilevel univariate linear regression model is
shown in Table 4. There was no statistically significant
Variable Placebo Dexamethasone P
difference between the use of dexamethasone and the
longitudinal change in total OHIP-14 (P = .42) and by
Teeth, n (%)
Impacted 26 (51) 25 (49) .99
domains (P > .05). The only variable associated with
Nonimpacted 23 (54.8) 19 (45.2) the OHRQoL was pain (P < .05), and the individuals
Race, n (%) who reported the highest pain scores had the highest
White 38 (55.1) 31 (44.9) .17 averages of overall OHIP-14 and by domain specific
Nonwhite 11 (45.8) 13 (54.2) over time. When stratifying the analysis by type of
Income, n (%) tooth (impacted and nonimpacted), there were no
>R$1,250.00 21 (61.8) 13 (38.2) .15 changes in the findings, with pain being the only vari-
#R$1,250.00 16 (44.4) 20 (55.6) able associated with the outcome (P < .01) (data
Education, n (%) not shown).
Higher education 11 (44) 14 (56) .40 Table 5 presents the linear regression models for the
Secondary education 21 (46.7) 24 (53.3)
outcomes of pain, edema, and mouth aperture. For
Elementary education 17 (73.9) 6 (26.1)
Profession, n (%)
mouth aperture, neither the drug (P = .12) nor any
Unemployed 23 (54.8) 19 (45.2) .50 other variable was statistically significant. The same
Urban area 20 (46.5) 23 (53.5) occurred for edema (P = .69) and pain (P = .57). How-
Rural area 6 (75) 2 (25) ever, the data were stratified for impacted and nonim-
Gender, n (%) pacted teeth and tested on the same regression
Female 32 (52.5) 29 (47.5) .30 models. For mouth aperture, the use of placebo de-
Male 17 (53.1) 15 (46.9) creases 0.419 cm the capacity of mouth aperture in
Age; average (standard 33.3 (12.5) 29.4 (10.6) .11 impacted tooth extractions in comparison with preop-
deviation) erative use of corticosteroids. For edema, no variable
Preoperatory edema; 49.5 (4.2) 49.3 (3.6) .62 showed statistically significant values. For the pain
average (standard
outcome, 2 variables influenced nonimpacted teeth,
deviation)
Preoperatory mouth 4.7 (0.5) 4.7 (0.6) .54
the use of placebo being responsible for increasing
aperture; average pain and people declaring themselves nonwhite with
(standard deviation) less pain.
Preoperatory overall 13.1 (8.6) 13.89 (8.4) .62
OHIP score; average
Discussion
(standard deviation)
Abbreviation: OHIP, Oral Health Impact Profile.
The present study demonstrated that the administra-
tion of 8 mg of dexamethasone, orally, before tooth
Pansard et al. Dental Extraction on Oral Health-Related Quality-of-
life and Clinical Outcomes. J Oral Maxillofac Surg 2020. extraction did not show improvement in the OHRQoL
and clinical outcomes, when compared with the pla-
cebo group, thus the hypothesis was rejected. Howev-
immediate postoperative period (first day), there is an er, pain has shown to have a negative influence on
increase in the average of the total OHIP-14 score OHRQoL, regardless of the experimental group, hav-
when compared with the preoperative period. After ing decreased the values of pain reported after tooth
the third day, the total score and the domain of the extraction, demonstrating the importance of the pro-
OHIP-14 decreased to a level below that was observed cedure. The use of previous medication seems to
in the period before the surgery, decreasing even more improve mouth aperture, especially in extractions of
until the seventh day as observed in Figure 2 and impacted teeth, although a statistically significant dif-
Table 2. Therefore, when comparing the means of to- ference was not detected.
tal OHIP-14 preoperatively and postoperatively, there The inflammatory response and the consequent
was a statistically significant difference (P < .01), postoperative complications associated with the
demonstrating an improvement in the OHRQoL after extraction of third molars are a challenging issue for
extraction, regardless of the experimental group. any surgeon.19 Moreover, there is still no consensus
For the outcomes of pain, mouth aperture, and on the cause and solution of these postoperative disor-
edema, there was no difference between the groups, ders that can harm patients’ quality-of-life.20,21 Thus,
although there was a greater mouth aperture in the well-designed clinical studies can improve the clinical
test group (Table 3). The clinical outcomes were protocols used daily. Our study showed the minimum
analyzed through the difference between the values number of patients necessary for differences to be
2153.e6 DENTAL EXTRACTION ON ORAL HEALTH-RELATED QUALITY-OF-LIFE AND CLINICAL OUTCOMES

detected and a triple blinding design, where the sur-

13.10  8.60
13.89  8.39

13.84  9.39
14.69  9.77

11.25  9.78
6.35  5.77
7.59  7.23
OHIP Score

9.86  8,0
geon responsible for the extractions has more than 8
Overall
years of experience as a specialist in bucco maxillofa-
cial surgery and traumatology. In addition, the preop-
erative and postoperative evaluations were performed
by a trained and calibrated surgeon, and most patients
0.84  1.52
0.87  1.58

0.94  1.62
0.86  1.55
0.53  1.15
0.73  1.32
0.20  0.61
0.29  0.73
Handicap

were young and healthy adult patients, which offers a

view of what is likely to occur in general
dental practice.
Although our study found no differences in the
Social Disability

OHRQoL and clinical parameters between groups of

1.53  1.63
1.41  1.59

1.75  1.74
1.5  1.66
1.14  1.31
1.26  1.95
0.75  1.14
0.93  1.56
patients, our findings are in line with a meta-
analysis, which demonstrated that preoperative
administration of corticosteroids in patients undergo-
ing third molar removal has a mild effect in the reduc-
tion of inflammatory clinical signs up to 7 days after
Psychological Disability

surgery.9 Our findings suggest that the preoperative

administration of corticosteroids reduces the initial
1.86  1.43
2.0  2.03

1.57  1.41
1.64  1.59
1.23  1.59
1.40  1.77
0.83  1.34
0.93  1.45
Table 2. OHIP-14 MEAN AND STANDARD DEVIATION BY DOMAINS ACCORDING TO EXPERIMENTAL GROUPS

edema and trismus compared with the controls. How-

ever, the authors do not mention the ideal time and
Pansard et al. Dental Extraction on Oral Health-Related Quality-of-life and Clinical Outcomes. J Oral Maxillofac Surg 2020.

dose; in addition, there was no assessment of

the OHRQoL.
The total scores and each domain of OHIP-14 of
both groups decreased after tooth extraction,
Physical Disability

showing an improvement in the OHRQoL. The surgi-

1.77  1.57
1.5  1.57

2.12  1.95
2.79  2.32
1.55  1.50
1.82  2.08
0.84  1.18
1.18  1.52

cal procedure of extraction, when indicated, is effi-

cient in improving the quality-of-life of individuals
regardless of the medication used previously. After
7 days, the individuals reached a total OHIP-14 average
lower than the average observed in the preoperative
period, indicating an improvement in the OHRQoL af-
Psychological

3.06  2.07
3.49  2.16

2.02  2.09
2.20  2.03
1.42  1.63
1.46  1.96
1.08  1.53
1.23  1.79
Discomfort

ter extraction, regardless of the experimental group. A

study that evaluated patients undergoing third molar
extraction concluded that there is a significant deteri-
oration in the OHRQoL in the immediate postopera-
tive period after surgery on third molars. However,
Physical Pain

3.28  2.02
3.49  1.75

3.98  2.00
4.16  2.17
3.08  2.09
3.27  2.34
2.06  1.61
2.20  1.75

there is an improvement in the quality-of-life in 6 to

7 days. Thus, the extraction of the teeth indicated
for extraction represents an improvement in the indi-
vidual’s health perception, which can be attributed to
an improvement in masticatory capacity and pain res-
Abbreviation: OHIP, Oral Health Impact Profile.
0.98  1.27
1.20  1.45

1.52  1.83
1.82  1.82
0.92  1.52
1.39  1.54
0.59  1.08
0.82  1.38
Functional
Limitation

olution and, consequently, in the individual’s social in-

teractions. This deterioration of quality-of-life is
associated with postoperative findings (trismus and
edema), which corroborates our findings. However,
in this study, no type of anti-inflammatory medication
was used in the postoperative period; it was only
advised to take 1 to 2 tablets of 500 mg of paracetamol
Placebo—preoperatively

Dexamethasone—3 days

Dexamethasone—7 days
Dexamethasone—day 1

with 8 mg of codeine every 4 hours or every 6 hours as

Experimental Groups

needed. These findings are important for understand-

Dexamethasone—
preoperatively

Placebo—3 days

Placebo—7 days

ing patients’ perceptions about changes in quality-of-

Placebo—day 1

life after third molar surgery and in informing patients

and surgeons when making treatment decisions.3
The protocol of the present study with oral admin-
istration of 8 mg of dexamethasone 1 hour before the
surgical procedure (2 tablets of 4 mg) was not efficient
PANSARD ET AL
FIGURE 2. Graph of the average of the total Oral Health Impact
Profile 14 score by experimental group.
Pansard et al. Dental Extraction on Oral Health-Related Quality-of-
life and Clinical Outcomes. J Oral Maxillofac Surg 2020.
in reducing the clinical signs and symptoms that can
impact the OHRQoL of individuals. In contrast, some
studies have shown positive effects on the use of dexa-
methasone. One study concluded that there was no
significant difference between individuals who under-
went tooth extraction and subsequently treated with
8 mg of dexamethasone injected intramuscularly
when compared with those treated with 8 mg of dexa-
methasone orally; however, both groups had positive
results in relation to facial edema, pain, and trismus.22
Another study concluded that the preoperative use of
submucosal dexamethasone effectively reduces post-
operative pain, swelling, and trismus, showing statisti-
cally significant results.23 The number of analgesic
pills used by patients in the test groups in this study
was lower compared with the control group, showing
clinically significant results.23 Lima et al24 used dexa-
methasone as a protocol every 8 hours for 3 days
and compared it with the use of diclofenac sodium
and concluded that the postoperative use of dexa-
methasone for 3 days was more effective in controlling
pain, trismus, and edema when compared with
diclofenac.24
Thus, it is clear that the use of medication seems to
play an important role in the outcomes after tooth
extraction despite our findings not showing any differ-
Table 3. MEAN AND STANDARD DEVIATION OF THE
VALUES OF CLINICAL OUTCOMES (EDEMA, PAIN, AND
APERTURE) FOR THE EXPERIMENTAL GROUPS
Clinical Outcomes Dexamethasone Placebo
Edema (in mm) 1.29 (1.88) 1.15 (1.48) .695
Pain 8.24 (5.92) 8.84 (6.02) .626
Mouth aperture 0.62 (0.79) 0.36 (0.50) .054
(in mm)
Pansard et al. Dental Extraction on Oral Health-Related Quality-of-
life and Clinical Outcomes. J Oral Maxillofac Surg 2020.
2153.e7
ence between the use of corticosteroids. Several
studies have been conducted evaluating clinical out-
comes of the use of dexamethasone with different dos-
ages in patients who underwent extraction of third
molars.22,24-28 However, few studies are found in the
literature evaluating OHRQoL of adults.2,12,29 Slade
et al10 reported the importance of these studies to
inform patients about the impacts on OHRQoL that
can be expected if they choose to extract or maintain
their third molars or if they develop symptoms related
to their third molars.
The present study has some limitations. The use of
dexamethasone in the test group was performed
only before the study. There is a possibility that differ-
ences may be found in administration regimens that
maintain the use of dexamethasone in the postopera-
tive period, especially during the first day when edema
is formed. Our study included individuals in need of
extraction of impacted and nonimpacted teeth. The
use of dexamethasone can be more effective when
we compare the clinical outcomes of individuals in
need of extraction of only impacted teeth, which
may indicate the need for more invasive procedures,
such as bone removal and, consequently, greater
edema, limited mouth aperture, and self-reported
pain. However, when stratifying our analysis by type
of tooth (impacted and nonimpacted), the findings re-
mained the same, but no Pell-Gregory classification of
extracted impacted tooth was made as well as no sta-
tistical correlation of postoperative edema and impac-
tion patterns of molars. Finally, our postoperative
protocol may have masked the real importance of us-
ing dexamethasone before tooth extraction, but
excluding this protocol could result in a significant
worsening in the postoperative quality-of-life of the pa-
tients included in the study, which could harm pa-
tients who participated in the study in relation to
those who did not participate. This study also has
some strengths. To the best of our knowledge, this is
the first study that evaluated the prior use of corticoids
to dental extractions on the patient-reported out-
comes over time, such as OHRQoL, in adults. Patient-
reported outcomes are essential to complement clin-
ical measures and improve clinical practices based
on patient preferences.30 Thus, the dental surgeon
can improve pharmacological management and the
effectiveness of surgical techniques, reducing postop-
erative pain and discomfort. In addition, we believe
P that the preoperative use of corticosteroids improves
postoperative complications.
The use of 8 mg of dexamethasone orally before the
procedure was not effective for improving the OHR-
QoL of adults submitted to tooth extraction. However,
especially for impacted teeth, the use of the drug im-
proves mouth aperture, which may justify its use in
such cases. Further studies involving the analysis of
 2153.e8
DENTAL EXTRACTION ON ORAL HEALTH-RELATED QUALITY-OF-LIFE AND CLINICAL OUTCOMES
Table 4. UNIVARIATE ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND TOTAL SCORE AND BY OHIP-14 DOMAINS OVER TIME, USING MULTILEVEL LINEAR
REGRESSION ANALYSIS

Functional Psychological
Limitation Physical Pain Discomfort Physical Disability Psychological Disability Social Disability Handicap Total—OHIP Score

Independent Variables b (SE) b (SE)

Drug
Placebo 1 1 1 1 1 1 1 1
Dexamethasone 0.28 (0.22) 0.16 (0.27) 0.22 (0.30) 0.23 (0.24) 0.12 (0.23) 0.02 (0.24) 0.10 (0.19) 1.02 (1.28)
Pain 0.16 (0.03)* 0.42 (0.4)* 0.23 (0.03)* 0.25 (0.04)* 0.17 (0.03)* 0.15 (0.03)* 0.09 (0.27)* 1.51 (0.15)*
Mouth aperture
Improved 1 1 1 1 1 1 1 1
Worsened 0.09 (0.25) 0.15 (0.31) 0.02 (0.33) 0.19 (0.27) 0.11 (0.27) 0.01 (0.27) 0.08 (0.20) 0.48 (1.43)
Edema
Improved 1 1 1 1 1 1 1 1
Worsened 0.37 (0.31) 0.22 (0.37) 0.09 (0.41) 0.24 (0.32) 0.07 (0.32) 0.07 (0.33) 0.21 (0.25) 1.31 (1.73)
Type of tooth
Nonimpacted 1 1 1 1 1 1 1 1
Impacted 0.06 (0.22) 0.02 (0.27) 0.11 (0.30) 0.04 (0.24) 0.16 (0.23) 0.14 (0.24) 0.26 (0.19) 0.14 (1.28)

Abbreviations: b, coefficient; OHIP, Oral Health Impact Profile; SE, standard error.
* Significant difference with P < .01.
Pansard et al. Dental Extraction on Oral Health-Related Quality-of-life and Clinical Outcomes. J Oral Maxillofac Surg 2020.
PANSARD ET AL
Table 5. ANALYSIS OF LINEAR REGRESSION WITH
INDEPENDENT VARIABLES AND THE EFFECT ON THE
CORRESPONDING OUTCOME
Confidence
Interval (95%)
Variable (Outcome) Result Lower Upper P ing House, 2011
Drug (mouth 0.419 0.841 0.002 .051
aperture—
impacted teeth)
Drug (pain— 3.634 0.434 6.835 .027
nonimpacted teeth)
Race (pain— 2.737 5.127 0.348 .026
nonimpacted teeth)
Pansard et al. Dental Extraction on Oral Health-Related Quality-of-
life and Clinical Outcomes. J Oral Maxillofac Surg 2020.
the OHRQoL must be performed, and other dosages
and means of administration must be tested.
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