The Efficacy of Intralesional

Dexamethasone in Surgery for

Impacted Thrid Molars : A
Randomized Controlled Trial
Journal Reading
Nanita K Koentara / 2095026
Pembimbing: drg. Susanti Bulan, Sp. BM
Introduction
The Efficacy of Intralesional
Dexamethasone in surgery for
Impacted Thrid Molars : A
Randomized Controlled Trial
Introduction
This study was undertaken to see The
role of corticosteroids in minimizing the cascade of
inflammatory response has been researched extensively in surgical removal of
third molars

Surgical 3th primary molar is the most common surgical

procedure that cause
array of complication in form of pain, swelling and trismus

Corticosteroid administration can reduce the

postoperative pain and trismus
Hypothesis
Behind the steroid usage
an action on arachidonic
acid metabolism and thus
is its action on
pain‑causing
prostaglandins, but its
action locally is still
debatable
Material &
Methods
The Efficacy of Intralesional
Dexamethasone in surgery for
Impacted Thrid Molars : A
Randomized Controlled Trial
Material & Methods
Patients with impacted mandibular molar in Maxillofacial Surgery
Department of King George’s University

Only Mesioangular
impacted mandibular
Asymtomatic young third molars
adults in the age ( Accordance with
group 20 -40 years Winter’s Classification )

The study was approved from Institutional Ethical

Committee and Written informed consent was taken and the
procedure was explained in detail to the patients in the language
they could understand
Randomization and
allocation concealment
Fourty‑five trial patients were distributed equally into three
groups by computer‑generated random numbers

Group A Group B Group C

Patients were administered Patients were administered Patient were control
dexamethasone sodium dexamethasone sodium group and were not
phosphate injection phosphate injection IP administered any
intraperitoneal (IP) 8 mg 8mg intralesionally steroid
intravenously 30 min (submucosally)
preoperatively 30 min preoperatively
Criteria of Assessment
a. Mouth opening (extent of trismus)
b. Postoperative edema (swelling)
c. Pain.

Exclusion
Criteria
• Patients with any systemic problem
• Pregnant or lactating mothers
• Operative procedure.
Patients Treatment
Local anasthesia
2% lignocaine
hydrochloride
& Postoperative
Semi-recline 1 : 100,000 medications included
positioin Adrenaline amoxicillin 500 mg
tid, metronidazole 400
mg tid a day, and
Interincisal Surgical removal a combination of
distance between of third molars ibuprofen 400 mg and
maxillary and was done by paracetamol 325 mg
mandibular first chisel and mallet tid, a day for 5 days.
incisors was noted with intermittent
in mm saline irrigation
Evaluation
Postoperative assessment was done on the 5th
day of the surgical procedure
Depict the severity of trismus was calculate by the
difference between the pre‑ and post‑interincisal
maximum distanced in milimeters.
Pain evaluation was done by calculating the number of
analgesic pills consumed in the 4 postoperative days.

Data were depicted as mean values and standard deviation.

ANOVA was used to compare the differences among the
three groups
Result
The Efficacy of Intralesional
Dexamethasone in surgery for
Impacted Thrid Molars : A
Randomized Controlled Trial
Results
Patients were divided into three groups. That did not show
any statistically significant differences and still comparable ( Shown in table 1 )
Assessment of trismus, pain and
swelling

It was seen to be almost similar in all the groups. The swelling altogether lasted
for 4–5 days. However, it was noted that significantly lesser
medication was used in Group A during surgery than that of Group B and Group C
There was a significant improvement in maximum mouth opening on the 7 th
postoperative day in Groups A and B as compared to Group C

Group B presented with a better condition in the incisal opening compared to

Group A
Discussion
The Efficacy of Intralesional
Dexamethasone in surgery for
Impacted Thrid Molars : A
Randomized Controlled Trial
 Discussuion
The anti‑inflammatory properties of glucocorticoids are well
established and published even though the mechanism of
its action is still not well documented

Corticosteroids induce decrease in permeability of capillary

endothelium which results into reduction of edema and
inflammation by decreasing the amount of fluid, proteins,
macrophages, and inflammatory cells entering in the area
of tissue injury
 Glucocorticoids
Have been regularly used for the last 30 years or more to minimize
the postoperative complications following the extraction of impacted
third molars.

Its rapid action and almost complete absorption, repeated doses are
necessary for the maintenance of optimal or adequate blood
concentration throughout the immediate postoperative period.
In this Study
Expected that repository effect similar to
intramuscular route can be obtained by local infiltration of
steroid in the submucosa around the surgical site chosen.

Submucosal infiltration forbids the usage of any added

armamentarium and does not need any added clinical expertise
or experience for the procedure.

These added benefits can be considered as the advantages of

submucosal technique over intravenous or intramuscular routes
of drug administration.
Dexamethasone
As a variety of corticosteroids have been explored
till date and has been chosen cause of its highly
potent along with high biologicalinterminable
potency and minimal sodium retention
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Make the patient to evaluate
themselves on the duration of
postoperative sweliing
This study clearly points out that no matter what
route of administration of steroids is followed, they
result in a more effectual reduction in the duration of
swelling when compared to the control
Trismus
Trismus can demonstrate the most comprehensive
assessment of postoperative inflammatory reaction.

Groups A and B : patients presented with a significant reduction in

trismus as compared to the control group ( group C )

They showed difference on the effect on maximum mouth

opening reduction which was calculated pre‑ and postoperatively.

Less reduction in incisal mouth opening was reported in Group B as

compared to Group A on the 7th postoperative day.
Uncontinuous Effect
The Group A & B patients showed a lower degree of pain ascompared to
the control group ( C ), but only on the day of surgical procedure not
considering any other days following the surgery
This can be explained based on the fact that steroids are rapidly
metabolized following surgery and therefore a single dose cannot provide
continuous effect

Group B patients presented with less significant pain compared to Group A.

Result
● Patients that receiving intralesional steroids
experienced lesser amount of pain and trismus as
compared to those who received steroids through
intravenous route.
● WHY ?, Intralesional steroids increase the
local concentration along with providing a
repository effect
● Intralesional steroids are also capable of
bypassing first‑pass metabolism up to some
extent when compared to intravenous steroids.
Conclusion
The Efficacy of Intralesional
Dexamethasone in surgery for
Impacted Thrid Molars : A
Randomized Controlled Trial
Conclusion
Considering previous studies which advocate the combination of
long‑acting anesthetics with nonsteroidal anti‑inflammatory agents toward
the reduction of postoperative pain

Future clinical trials should be done and promoted to compare the

combined effect of steroids, on‑steroidal anti ‑inflammatory drugs, and
long‑acting anesthetics in the reduction of postoperative sequelae.

Sensitive measuring techniques that can quantitatively describe the

reduction in postsurgical swelling are the need of the hour.
Take Home
Messages
The Efficacy of Intralesional
Dexamethasone in surgery for
Impacted Thrid Molars : A
Randomized Controlled Trial
 hormon yang diproduksi oleh
Kortikosteroid  kelenjar adrenal bagian korteks yang
secara struktural mengandung inti
steroid.

Glukokortikoid  mengatur metabolisme karbohidrat &
protein
• Utama pada manusia: hidrokortison (kortisol)
• Dihasilkan di Korteks
• C/ dexametason, prednisolone, betametason, kortison asetat,
triamnisolon, metilprednisolon, deflazacort, hidrokortison

Mineralokortikoid  mengatur keseimbangan elektrolit

• Utama pada manusia: Aldosteron
• Dihasilkan di Medula Adrenal
• C/ fludrocortisone, desoxycorticosterone acetate
 Kortikosteroid
Efek Efek Samping
1. Anti-Inflamasi 1. Gangguan cairan dan
2. Analgesik elektrolit
3. Antiemetik 2. Demineralisasi tulang
4. Anti-Anoreksia 3. Penyakit gastrointestinal
4. Gangguan metabolism
glukosa
5. Gagal jantung kongestif
6. Reaksi alergi
 Farmakokinetik Kortikosteroid
- Absorbsi: Oral, IV (memerlukan konsentrasi tinggi dalam darah),
IM (u/ efek yang lebih lama), subkutan & jalur topikal (kulit, mata,
inhalasi, intranasal, intra artikular)
- Distribusi: Waktu paruh plasma dari berbagai jenis steroid tidak
menentukan durasi kerja dari kortikosteroid. Hidrokortison,
prednisone & prednisolon harus diberikan lebih sering dibandingkan
dengan deksametason. Waktu paruh dari kortisol pada sirkulasi yang
normal ± 60-90 menit, yang akan meningkat apabila hydrokortison
diberikan dalam dosis besar ataupun pada stress, hypothyroidism
ataupun penyakit hepar. Hanya 1% kortisol yang akan diekskresi ke
urin dalam keadaan tidak termetabolisme, sekitar 20% akan
dikonversi di ginjal dan organ lain menjadi 11-hydroxysteroid.
 Cont…
- Metabolisme: beberapa terjadi di hepar dan
sebagian terjadi di ginjal (sekitar 70% kortisol
dimetabolisme di hepar)
- Ekskresi: Sebagian besar akan dieksresi di urin dan
sangat sedikit di ekskresi di feses dan empedu.
 Farmakodinamik
Kortikosteroid
• Kortikosteroid memengaruhi:
• Metabolisme karbohidrat
• Metabolisme protein & lemak
• Fungsi system kardiovaskular
• Fungsi ginjal
• Fungsi otot lurik
• Sistem saraf & organ lain
• Pada waktu memasuki jaringan, glukokortikoid berdifusi
atau ditranspor menembus sel membrane & terikat pada
kompleks reseptor sistoplasmik glukokortikoid heat-
shock protein kompleks
 Farmakodinamik
Kortikosteroid
• Pada waktu memasuki jaringan, glukokortikoid
berdifusi atau ditranspor menembus sel membrane dan
terikat pada kompleks reseptor sitoplasmik
glukokortikoid heat-shock protein kompleks.
• Heat-shock protein dilepaskan dan kemudian kompleks
hormon reseptor ditranspor ke dalam inti, dimana akan
berinteraksi dengan respon unsur respon
glukokortikoid pada berbagai gen dan protein pengatur
yg lain dan merangsang atau menghambat ekspresinya.
Peran Kortikosteroid sebagai
Analgetik/Anti Inflamasi (Metabolisme
Asam Arakidonat)
Membrane Phospolipids

Phospolipase A2

Lipoxygenase
Arachidonic Acid Leukotrienes

Non-Selective Cox
Physiological Regulation Inhibitors Inflammatory response by
Preformed by COX-1 newly expressed COX-2

Cox-2 Selective
NSAID’s

PGE2 PGI2 TXA2 PGE2, PGI2, TXA2, Other

GI Chemical Mediators
GI Protection Platelet fuction
Protection Platelet Fuction Regulation of Inflammation
Regulation of blood flow
blood flow
Pain
Kidney Fuction Fever
Yang Harus Diperhatikan Dokter Gigi
dalam Memberikan Steroid
• Kortikosteroid bila digunakan dalam dosis tinggi dan jangka
panjang  penekanan fungsi kelenjar adrenal, penekanan
system imun, sarcoma kaposi, miopati, efek pada mata dan
pangguan psikiatrik  diperlukan penurunan dosis secara
bertahap (tapering off)

Tappering off  penurunan dosis obat tertentu ketika obat

hendak dihentikan penggunaannya.

Tujuan  agar tubuh tidak mengalami gangguan akibat

penghentian obat bersifat tiba-tiba sehingga tidak mengalami
withdrawal syndrome
Cont…
Prinsip tapering off dosis steroid:
• Pada penggunaan steroid secara sistemik >2 minggu
• Mempertimbangkan risiko kemingkinan kembalinya penyakit,
bila terjadi kekambuhan dosis harus dinaikkan kembali
• Penggunaan selama 2-4 minggu, dilakukan 1-2 minggu
• > 4 minggu dilakukan penurunan dosis bertahap selama 1-2
bulan
• Tidak dibutuhkan pada pasien yg mendapatkan steroid alternate-
day atau di bawah dosis fisiologis dalam jangka <1 bulan
Penggunaan Dosis Tunggal
● Steroid bekerja dengan menekan aksis HPA (Hipotalamus pituitary adrenal)
yang mengatur reaksi terhadap stress, pencernaan, kekebalan tubuh, suasana
hati dan emosi
● Dokter diharapkan menggunakan dosis terkecil ( tunggal )yang memberikan
efek klinis dan dalam jangka waktu yang paling singkat,
● Penggunaan steroid di atas kadar steroid endogen (dosis fisiologis) dapat
menyebabkan risiko penekanan HPA aksis yang lebih berat.
● Akibatnya Ketika terjadi penurunan dosis steroid pasca penggunaan steroid
dosis tinggi jangka Panjang dapat menyebabkan sindroma ketergantungan
steroid , insufisiensi adrenal dan kambuhnya penyakit yang semula ingin
diobati
Indikasi Farmakologis Kortikosteroid
1. Reaksi Alergi
2. Kelainan Vaskular Kolagen
3. Penyakit Mata
4. Penyakit Saluran Cerna
5. Kelainan Hematologik
6. Inflamasi Sistemik
7. Gangguan Peradangan Tulang dan Sendi
8. Kelainan Neurologik
9. Transplantasi Organ
10. Penyakit Pary
11. Kelainan Ginjal
12. Penyakit Kulit
13. Penyakit Tiroid
14. Lain-lain (hiperkalsemia, mountain sickness)
Thank You