Vol. 116 No.

1 July 2013

Evaluation of postoperative discomfort following third molar

surgery using submucosal dexamethasone e a randomized
observer blind prospective study
Riaz Warraich, MD, DDS,a Muhammad Faisal, DDS,b Madiha Rana, MSc, PhD,c Anjum Shaheen, DDS, PhD,d
Nils-Claudius Gellrich, MD, DDS,e and Majeed Rana, MD, DDSf
King Edward University, Lahore, Pakistan; and Hannover Medical School, Hannover, Germany

Background. Surgical removal of impacted lower third molar is still the most frequent procedure done by Oral and
Maxillofacial surgeons and is often associated with pain, swelling and trismus. These postoperative sequelae can cause distress
to the patient as a result of tissue trauma and affect the patients quality of life after surgery. Use of antiseptic mouthwashes,
drains, muscle relaxants, cryotherapy, antibiotics, corticosteroids and physiotherapy seems to decrease postoperative
discomfort. Among them corticosteroids are well-known adjuncts to surgery for suppressing tissue mediators of inflammation,
thereby reducing transudation of fluids and lessening edema. The rationale of this study is to determine the effectiveness of
submucosal injection of dexamethasone in reducing postoperative discomfort after third molar surgery.
Patients and Methods. 100 patients requiring surgical removal of third molar under local anesthesia were randomly divided
into 2 groups, group I receiving 4 mg dexamethasone as submucosal injection and the control group II received no steroid
administration. Facial swelling was quantified by anatomical facial landmarks. Furthermore, pain and patient satisfaction, as
well as neurological score and the degree of mouth opening were observed from each patient.
Results. Patients receiving dexamethasone showed significant reduction in pain, swelling, trismus, a tendency to less
neurological complaints and improved quality of life compared with the control group.
Conclusions. Submucosal injection of dexamethasone is more efficient to manage postoperative discomfort after removal of
third molars compared to no steroid administration. (Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:16-22)

The surgical extraction of lower third molars is the most

frequent intervention in oral surgery.1 This procedure is
often associated with signicant postoperative sequelae
that may have both a biological and social impact.2,3
This is because molars show a high incidence of
impaction and are often associated to highly diverse
disorders such as pericoronitis, periodontal defects in
the distal aspect of the second molar, caries of the third
molar or second molar, pressure resorption of second
molar, different types of cysts and odontogenic tumors
and neurogenic pain, provoking or aggravating orthodontic problems and obstruction of placement of
a complete or partial denture.4 The surgical procedure
which usually involves incision, ap reection and
bone removal to expose the impacted tooth is associated
a

Professor and Head, Department of Oral and Maxillofacial Surgery,

King Edward University.
b
Assistant Professor, Department of Oral and Maxillofacial Surgery,
King Edward University.
c
Assistant Professor, Department of Craniomaxillofacial Surgery,
Hannover Medical School.
d
Assistant Professor, Department of Oral and Maxillofacial Surgery,
King Edward University.
e
Professor and Head, Department of Craniomaxillofacial Surgery,
Hannover Medical School.
f
Consultant, Department of Craniomaxillofacial Surgery, Hannover
Medical School.
Received for publication Nov 9, 2012; accepted for publication Dec
14, 2012.
2013 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2012.12.007

16

with postoperative pain, swelling and trismus. The

adverse effects of wisdom tooth surgery on the quality
of life has been reported to show a threefold increase in
patients who experience pain, swelling or trismus alone
or in combinations; compared to those who were
asymptomatic.5 Many clinical studies investigate treatments to reduce postoperative complications by using
antiseptic mouthwashes, use of drains, ap design,
antibiotics, corticosteroid treatment, muscle relaxant
and physiotherapy.6 Among them corticosteroids are
well-known adjuncts to surgery for suppressing tissue
mediators of inammation, thereby reducing transudation of uids and lessening edema.7
As a routine protocol, antibiotics and NSAIDs
(non-steroidal anti inammatory drugs) have been
prescribed pre- and postoperatively. The introduction of
NSAIDs has signicantly altered the management of

Statement of Clinical Relevance

This study provides modern treatment strategies and
effectiveness of submucosal injection of dexamethasone on swelling, pain, trismus, neurological complaints and patient satisfaction after third molar
surgery. This study provides a basis for the routine
administration of preoperative submucosal dexamethasone in a subtherapeutic dose to reduce the
intensity of post surgical sequelae such as pain,
swelling and trismus.

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Volume 116, Number 1

postoperative pain in dentistry and medicine. By

administering the NSAIDs prior to pain onset, drug
absorption would have begun and therapeutic blood
level will be present at the time of pain onset. Secondly,
the presence of cyclooxygenase inhibitor may limit
the production of prostaglandins and prostacyclins
associated with pain and edema.8 Corticosteroids
(Dexamethasone, Prednisolone) dramatically reduce the
manifestations of inammation including redness,
swelling, heat and tenderness that are commonly
present at the inammatory site. The effect of dexamethasone on the inammatory process is the result of
a number of actions including the redistribution of
leukocytes to other body compartments, thereby
lowering their blood concentrations. Also involved is
the inhibition phospholipase A2 (due to steroid mediated elevation of lipocortin) which blocks the release of
arachidonic acid, the precursor of prostaglandins and
leukotrienes from membrane bound phospholipids.9
Clinical trials in Oral Surgery have also supported the
hypothesis that preemptive NSAIDs and Corticosteroids are effective in delaying and preventing many
postoperative sequelae.5
Topographical considerations make it difcult to
quantify facial volume of swelling. However, different
methods of measuring facial swelling have been
proposed, e.g., verbal response scales (VRS), mechanical
methods (cephalostat, calipers, registration of reference
points or landmarks), ultrasound, photographic techniques, computer tomography (CT), magnetic resonance
imaging (MRI) and optical face scanning with mirror
construction.10-15
The aim of this study was to evaluate the effectiveness of submucosal injection of dexamethasone on
swelling, pain, trismus, neurological complaints and
patient satisfaction after third molar surgery.

MATERIALS AND METHODS

The study was approved by the local ethics committee
at the Nishtar Institute of Dentistry (NID/01-2008). At
the beginning of the study, written informed consent
was obtained from each patient.
Patients
100 healthy male and female patients (M 26.9,
SD 4.45 years) attending the Oral and Maxillofacial
Surgery requiring surgical removal of upper third
molars and bilateral impacted lower third under local
anesthesia were included. Only patients, who required
an osteotomy of the lower mandible wisdom teeth, were
included in the study. They were divided randomly into
2 treatment groups. The observer did not know about
the kind of therapy applied at the time of the patient
examinations.

ORIGINAL ARTICLE
Warraich et al. 17

Fig. 1. This gure shows an orthopantomogramm (OPT) of

a patient, who fullls the criteria by Pell & Gregory level B and C.

Surgical procedure
The surgical procedure took place using local anesthesia. Surgical procedure involved adequate elevation
and reection of adequate buccal mucoperiosteal ap
under local anesthesia (2% lidocaine hydrochloride
with 1:100,000 adrenaline), buccal and distal guttering
to facilitate delivery of the third molar and then
meticulous irrigation of the surgical site with normal
saline (0.9%). Flap was repositioned and sutured. Only
in group I, patients were given injection of dexamethasone (Decadron 4 mg/mL; Merck Sharp & Dhome of
Pakistan, Ltd.) in submucosa before the start of the
surgical procedure (in the mucogingival junction on the
buccal aspect of molars and loose submucosa distal to
the third molar). A single experienced surgeon has
performed the surgical procedure.
Study including criteria and protocols
Only patients with a Pell & Gregory level B and C were
included in this study (Figure 1). Patients who needed
a simple extraction of wisdom teeth of the mandible were
not included in this study. Clinical signicant medical
history was taken to exclude participants on the basis of
known hypersensitivity, allergies or idiosyncratic reaction to any study medications, hepatic or renal disease,
blood dyscrasias, heart disease, gastric ulcer, cushing
syndrome or adrenocortical insufciency, pregnancy and
lactation, recent anti-inammatory treatment or chronic
use of medications that would obscure assessment of
anti-inammatory response, infected third molar with
associated swelling. All patients were examined and
scanned on xed dates using standardized methods and
techniques.
Thus every patient received the same postoperative
analgetic (1st day: ibuprofen 600 mg 3 times per day, 2nd
day: ibuprofen 600 mg 2 times per day, 3rd day: ibuprofen 600 mg 1 time per day, 4th day: ibuprofen 600 mg
1 time per day) and no antibiotic prophylaxis therapy.
During the study the following parameters were
assessed: swelling, pain, neurological complaints, patient satisfaction and mouth opening.

ORAL AND MAXILLOFACIAL SURGERY

18 Warraich et al.

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July 2013

Fig. 2. Consort ow diagram illustrate that at the time of presentation 166 patients were assessed for eligibility to be included in the
study. Out of these 106 patients were randomly allocated in two groups. Six patients were not available for follow-up.

Consort flow diagram

At the time of presentation 166 patients were assessed
for eligibility to be included in the study. Out of these
36% of the patients (n 60) were not included in the
study as 24% patients (n 41) did not meet the
inclusion criteria while 11% (n 19) did not want to
participate in the study. A total of 106 patients were
randomly allocated in 2 groups with 53 patients allocated in each group for intervention. In submucosal
dexamethasone group 100% patients (n 53) received
the selected intervention. In the No dexamethasone
group 100% patients (n 53) received the selected
intervention. Among the 53 patients who received
submucosal injection of dexamethasone 3.7% (n 2)
were lost to follow-up as these patients come from far
areas and could not travel due to economic or personal
reasons. While the 53 patients who did not receive
dexamethasone 1.8% (n 1) were lost to follow-up.
The 50 patients who received dexamethasone in group I
were available for follow-up, 1 of them had their data
lost during the data analysis procedure. So the total
number of patients who were analyzed for submucosal
dexamethasone was 50.
The 52 patients who received no dexamethasone in
group II were available for follow-up, 2 of them had
their data lost during the data analysis procedure. So the

total number of patients who were analyzed for no

dexamethasone was 50 (Figure 2).
Sample size
Sample size of 100 cases (50 cases in each group) with
95% condence level, 80% power of study and taking
magnitude of postoperative pain, i.e., 0.5 0.51 and
1.3 0.62 and magnitude of facial swelling, i.e.,
31 1.58 and 32.04 1.5 in group I and group II
undergoing third molar surgery.
Randomization
Randomization was done using a computer based software EpiCalc2000 (Brixton Health). The software was
used to generate serial numbers 1-100 into 2 groups
randomly and those patients who fullled the inclusion
criteria were allocated serial numbers according to date
and sequence of admission to hospital. The person
responsible for conducting the measurements at the time
of assessment of variables was blindfolded regarding the
type of procedure that was conducted.
Measurement of facial width (swelling)
A measuring tape was used to measure facial width and
swelling in one dimension only due to nonavailability

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Volume 116, Number 1

of 3D optical scanner. This method seems to be a useful

alternative for assessing facial swelling. A measuring
tape was used to measure facial width and swelling in
1 dimension only. The tip of the tragus of the right and
left ears with the gonium in between were used as
reference landmarks. The operator has repeated the
procedure three times on each patient and the average
of the measurements has been taken in centimeters
and recorded. The measurements were carried out just
before the surgery and on postoperative day 2 as
swelling are not observed immediately after surgery
but rather begin gradually peaking 2 days after the
extraction.
Postoperative pain analysis
Postoperative pain analysis was conducted with the
help of a visual analog scale (VAS) on a daily base
from 2nd to 10th day, where the patients should rate
their pain on a score from 0 to 10, with 0 describing
a situation without pain and 10 denoting a maximum
intensity of pain.
Measurement of mouth opening
Trismus was calculated with interincisal mouth opening
and was measured with a caliper. The result was quoted
in millimeters and observed at 5 days: before surgery
(T0), directly after surgery (T1), on the 2nd (T2), the
10th (T3) and the 28th (T4) postoperative day.
Neurological analysis
The neurological analysis was performed bilaterally. It
was used to be able to evaluate nerve dysfunctions. The
skin of the infraorbital, mental region, upper and lower
lip were checked using a cotton test for touch sensation,
a pinprick test using a needle for sharp pain and
a blunt instrument for testing pressure. Additionally, a
two point discrimination test was executed on these
regions. The same procedure was accomplished for the
lower lip and the mental nerve skin region. The results
were recorded on a score that ranges between 0 and
13, with 13 being the worst neurological score. The
neurological score was assessed at 3 points in time:
before surgery (T0), on the 2nd (T1) and the 28th (T2)
postoperative day.
Patients satisfactory
Each patient was asked to complete a questionnaire on
the 10th postoperative day. The question was how they
evaluated satisfaction and convenience of the applied
postoperative cooling therapy on a subjective base. The
grading scale ranged from 1 to 4, where 1 stands for
very satised and 4 for not satised.

ORIGINAL ARTICLE
Warraich et al. 19

Table I. Baseline characteristics of patients

Decadron
Gender female e no./total
no. (%)
Age (y)  SD
BMI (kg/m2)  SD
Surgical procedure duration
(min)  SD

15/5027

Conventional P value
13/5025

26.90  4.42 27.04  4.53

22.6  3.8
22.9  3.6
69.2  18.8 66.3  17

.65
.87
.26
.69

Statistical analysis
Regarding the statistical analysis, all data is expressed
as mean values  1 SEM. For repeating measures
a one-way analysis of variance (ANOVA) with post hoc
Bonferronis test for multiple comparisons of means
was applied. Since the observed parameters consist
above all of dichotomous variables, a c2-test and
a Wilcoxon-test were conducted to detect differences
between group I and group II. To check for statistical
signicance of quantitative variables the Student t-test
was used, denoting a P value of <.05 as signicant.
The statistical analysis was conducted using SPSS for
Windows version 14.0 (SPSS Inc., Chicago, IL, USA).

RESULTS
Baseline characteristics
A total of 100 patients requiring surgical removal of
unilateral or bilateral impacted lower third molar teeth
under local anesthesia were selected in this study.
Patients were randomly allocated in 2 groups with
1 group (case group) which were treated with dexamethasone and the second group called control group
which were not given dexamethasone injection. The
clinical and demographic characteristics of patients in
both groups are shown in Table I. Both groups showed
no statistical signicances regarding gender, age, body
mass index (BMI) and surgery duration.
Postoperative swelling
Figure 3 demonstrates the differences in facial swelling
between groups observed over time. Mean facial
swelling was signicantly increased after surgery in
both groups (within subject effect; P .0005) while on
the 2nd postoperative day, mean facial swelling score
was signicantly less in those patients who were treated
with dexamethasone than control (P .02).
Postoperative pain
Postoperative pain intensity between groups. The
median pain score from 2nd to 10th day was signicantly lower in case than control (2 vs. 6,7; P < .0005)
(Figure 4).

ORAL AND MAXILLOFACIAL SURGERY

20 Warraich et al.

Fig. 3. This gure demonstrates the amount of swelling in mm

of both groups at different time points. At 2nd postoperative
mean facial swelling score was signicantly less in those
patients who were treated with dexamethasone than control.

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July 2013

Fig. 5. Pre-operative mouth opening values did not differ

signicantly in both groups. On the 2nd postoperative day
a signicant reduction of mouth opening could be revealed in
both groups. The reduction of mouth opening was signicantly lower in the dexamethasone group compared to
conventional group.

Fig. 4. Pain was calculated in terms of a visual analog scale

from subjective analysis ranging from 0 to 10. A signicant
increase of pain was reported in the control group compared to
dexamethasone group during 2nd and 10th postoperative days.

Fig. 6. The overall satisfaction was signicantly lower of

patients receiving no steroid therapy compared to patients
receiving dexamethasone therapy by Decadron.

Measurement of trismus
Preoperative, there was no signicant difference between
the groups with regard to reduction in mouth opening
whereas on the 2nd postoperative day the mean trismus
scores were lower in control than case (29.36 mm vs.
32.8 mm; P .004) as presented in Figure 5.

Patient satisfaction
Regarding the patients satisfaction, which was assessed at 10th day after surgery, a statistically signicant difference between group I and group II could be
detected (dexamethasone: 1.8  0.2, control: 3.0  0.3,
P .003) (Figure 6).

Postoperative neurological score

There were no statistical signicant differences found
between both groups concerning the neurological score
10 days after third molar extraction (df 2; Chisquare 7.714; P .021).

DISCUSSION
Corticosteroids such as dexamethasone and methylprednisolone have been used extensively in dentoalveolar surgery due to their nearly pure glucocorticoid
effects, virtually no mineralocorticoid effects, and the
least adverse effects on leukocyte chemotaxis.16,17

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Volume 116, Number 1

Dexamethasone has a longer duration of action than

methylprednisolone and is considered more potent.18
The submucosal injection of dexamethasone has been
reported to have a signicant effect on edema in 2
previous studies both of which reported a signicant
reduction in edema in the immediate postoperative
period compared with controls, but only a limited effect
on trismus and pain.16,17
In our study, submucosal injection of dexamethasone
4 mg preoperatively resulted in a signicant decrease in
edema on postoperative day 2 with results. As postoperative edema at the site of third molar surgery is
related to the soft tissue trauma and bone cutting,
application of steroids at the same very site results in
reduced inammation related events. Another possible
advantage of using submucosal injection of dexamethasone at the site of surgery is its painless administration
due to already achieved local anesthesia of the operative eld.
Acute postoperative pain following third molar
extraction is predominantly a consequence of inammation caused by tissue injury.19 Contrary to previous
studies, our patients have experienced signicantly less
pain in submucosal group compared with controls.
Graziani et al. did not state that which analgesic was
prescribed and pain was only assessed subjectively on
visual analog scale (VAS) without the number of
analgesics taken postoperatively but in our study has
denitely resulted in reduction in the number of analgesics tablets used after surgery in case group. This
decrease in pain may be attributed to dexamethasone
which might have increased patientss reaction to pain
by suppressing tissue bradykinin and b-endorphin
levels.20 As known, bradykinin and kallidin are the
2 kinins that act independently as well as synergistically
with products of the arachidonic acid cascade to
produce both hyperalgesia as well as increased vascular
permeability.21
Apart from the two principal variables of our study
i.e., pain and swelling, trismus being one of the postoperative sequelae of third molar surgery has also been
calculated. Graziani et al.20 has reported that endoalveolar application of dexamethasone has resulted in
reduced trismus but its submucosal administration has
not produced notable results. But, in our scenario,
submucosal injection of dexamethasone has not resulted in signicant decrease in trismus possibly because
of its application at the site of injury. Steroids though
do not have any direct inuence on muscle contraction,
decrease in trismus would be secondarily related to less
degree of local inammation.
It has been shown that the healing process and the
possible complaints after removal of third molars can be
inuenced by various factors such as surgeon experience, age and gender of the patient, necessity of tooth

ORIGINAL ARTICLE
Warraich et al. 21

sectioning or of bone removal.22-25 Another variable

that can have an inuence on the degree of facial
swelling is the duration of operating time that again is
related to surgical difculties in extraction.26 Since
operating time was not signicant different in both
groups this factor does not have any impact on the
results.

CONCLUSION
Conclusion of this study provides a basis for the routine
administration of preoperative submucosal dexamethasone in a subtherapeutic dose to reduce the intensity of
post surgical sequelae such as pain, swelling and
trismus. Submucosal route is an effective alternate to
dexamethasone given systemically as it offers a high
drug concentration at the site of injury. It represents
a simple, easy-to-use and cost-effective treatment
alternative to mouthwashes, drains, muscle relaxants,
cryotherapy, antibiotics and physiotherapy.
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Reprint requests:
Majeed Rana, MD, DDS
Department of Craniomaxillofacial Surgery
Hannover Medical School
Carl-Neuberg-Street 1
D-30625 Hannover, Germany
rana.majeed@mh-hannover.de