Effects of Dexamethasone in Third Molar Surgery–A Review

 

 

ABSTRACT:

Generally, third molars have been found to erupt between the ages of 17 and 21 years. Third molar eruption and continuous positional changes after eruption can be related not only with race but also with nature of the diet, the intensity of the use of the masticatory apparatus and possibly due to genetic background. Dexamethasone is a potent synthetic member of the glucocorticoid class of steroid drugs that has anti-inflammatory and immunosuppressant effects. It is 25 times more potent than cortisol in its glucocorticoid effect, while having minimal mineralocorticoid effect. Every patient after third molar surgeries have swelling, edema and pain. Dexamethasone can be intramuscular, intravenous and sub mucosal can be preoperative, perioperative or post operative appears to be effective in the prevention of post operative edema. This article reviews about the structure, mechanism and techniques used in drug delivary. Dexamethasone is a corticosteroid that prevents release of substance in the body that cause inflammation.

 

 

INTRODUCTION:

Dexamethasone have been used extensively in oral and maxillofacial surgery due to their nearly pure glucocorticoid effects and no minerlocorticoid effects on leukocyte chemotaxis [1][2]. Different steroids have been used in various oral procedures which range from root canel, Periodontal surgeries, impactions, trauma, orthognathic surgeries, release of fibrous bands in oral sub mucous fibrosis[3][4]. Dexamethasone is one of the most potent anti inflammatory drugs and for this reason has been used following minor oral surgery. Shouldn’t use dexamethasone when patient has any fungal infection in any part of the body. Dexamethasone can weaken your immune system, making it easier for you to get an infection. Steroids can also worsen an infection you already have or reactivate an infection you recently had. Dexamethasone can’t be given for patients with liver disease (such as cirrhosis), kidney disease, a thyroid disorder, diabetes, a history of malaria, stomach ulcers, high blood pressure and pregnant women. Long term use of dexamethasone can lead to symptoms such as thinning skin, easy bruising, change in shape and location of body fat and menstrual problems[5][6]. At equal anti inflammatory doses dexamethasone essentially lacks the sodium retaining properties of hydrocortisone and is three thousand times more soluble than hydrocortisone in water at 25⁰C[7].

 

The normal hormonal effects associated with prolonged steroid therapy are essentially absent with a single infection. If undesirable hormonal effects do occur, they are reversible and disappear when the steroid is discontinued[8].

 

Mechanism of action:

The amount of endogenous cortisol from the adrenal cortex does not appear to alter the process of inflammation significantly; on the other hand, large doses of exogenous cortisol or synthetic steroids appear to block all stages. Steroids prevent diapedesis, the initial leakage of fluids from the capiilaries, and stabilize the membranes of the cellular lysosomes which hold large quantities of hydrolytic enzymes[9][10]. There is also a decrease in the formation of bradykini a powerful vasodilating substance. Glucocorticoids act by controlling the rate of synthesis of anti inflammatory proteins have shown that glucocorticoids can induce the release of antiphospholipase proteins which presumably can inhibit the release of arachidonic acid and its metabolism to prostaglandins and thromboxanes, which increase capillary permeability. The low analgesic effect at the low dose suggests that any putative analgesic effect of glucocorticoids occur by a mechanism that is distinct from those mechanisms responsible for reducing facial swelling[11][12].

 

Technique used for drug delivery:

Dexamethasone is been delivered for third molar surgies by either oral, intravenous, intramuscular in masseter, gluteal or deltoid region, sub mucosal preventing postsurgical pain is controversial[13][14]. Corticosteroids alone do not seem to have a clinically significant analgesic effect but it has been reported that steroids can be related to a reduction in the number of analgesic tablets used after surgical extractions. Dexamethasone in particular appears to decrease pain after surgery [15][16][17]. Both sub- mucosal and endo-alveolar administration of dexamethasone are effective in reducing postoperative sequelae of surgical removal of lower wisdom teeth. On the second postoperative day, facial edema showed a significant reduction in both dexamethasone 4- mg and dexamethasone 8-mg groups compared with the control group, but no significant differences were observed between the 2 dosage regimens of dexamethasone[18][19].

 

Submucosal injection of dexamethasone 4 mg is an effective therapeutic strategy for improving the quality of life after surgical removal of impacted lower third molars with a comparable effect on postoperative sequelae to intramuscular injection. It offers a simple, safe, painless, noninvasive, and cost effective therapeutic option for moderate and severe cases. 8mg of dexamethasone intramuscularly, 1h before surgery significantly reduced postoperative swelling on day 2, when most swelling occurs. The significant swelling reduction probably led to decreased tissue tension related to pain. The effects of preoperative dexamethasone (4 and 8 mg) consumption, to decrease pain, facial swelling and trismus[20][21]. Dexamethasone of 8 mg was more effective than that of 4 mg at reducing facial swelling and trismus. No significant differences were observed between the 8 mg dexamethasone Intramuscular injection group and the 8 mg dexamethasone consumption group in this study. Both groups reported positive effects on facial swelling, pain and trismus on 1, 3 and 7 postoperative days [22]. Therefore, dentists can use 8 mg dexamethasone Intramuscular injection or consumption for third molar surgery [23][24].

 

Side effects of dexamethasone:

~Impaired vision

~Swelling, rapid weight gain

~severe depression, unusual thoughts or behaviour, seizure.

~Sleep problem

~Slow wound healing

~Headache, dizziness, spinning sensation

~Nausea, stomach pain, bloating

~Muscle weakness or

~Increased sweating [25][26].

 

CONCLUSION:

From reviews seen, we could accept dexamethasone as the choice of the drug in third molar surgeries due to its half life and no sodium retaining capacity in reducing the pain and swelling. Submucosal dexamethasone may be preferred since having similar results as intramuscular and no pain while injecting it. The drug has good result when given preoperatively or perioperatively than postoperative. It should be made mandatory to give this drug in either of the routes in third molar surgery, as all routes has given significant improvement in pain and swelling unless otherwise dexamethasone is contraindicated.

When the dexamethasone is contraindicated. We found that the dosage of 8 mg of dexamethasone was statistically more efficient in the trismus and swelling control than the lower dosage, without any evidence in the reduction of pain levels after surgery. Dexamethasone resulted in a significant reduction in pain 4h postoperatively, and eliminated the need for opioid analgesia in the postoperative period. The incidence of severe swelling was also reduced significantly, but there was no effect an trismus. Postoperative nausea and vomiting were significantly lower in the dexamethasone group. We conclude that the use of prophylactic oral dexamethasone is useful in reducing postoperative analgesia requirements in this group of patients, and may facilitate surgery performed on a day case basis.

 

REFERENCE:

1.        Peterson LJ. Principles of management of impacted teeth. In: Peterson LJ, Ellis E III, Hupp JR, Tucker MR, eds. Contemporary oral and Maxillofacial Surgery. 4th ed. St Louis: CV Mosby; 2003:184-213.

2.        Montgomery MT, Hogg JP, Roberts DL, Redding SW. The use of glucocorticosteroids to lessen the inflammatory sequelae following third molar surgery. J Oral Maxillofac Surg. 1990; 48:179.

3.        D. P. Von Arx, Simpson M. T, The effect of dexamethasone on neurapraxia following third molar surgery. British Journal of Oral and Maxillofacial Surgery (1989) 27, 477- 480

4.        Hooley, J. R. & Hohl. T. H. Use of steroids in the prevention of some complications after traumatic oral surgery. Journal of Oral Surgery (1974). 32, 864.

5.        Eugen’e J. Messer, John J. Keller, The use of intraoral dexamethasone after extraction of mandibular third molars. Oral Surgery, Oral Medicine, Oral Pathology. Volume 40, Issue 5, November 1975, Pages 594–598

6.        Maano Milles, Paul J. Desjardins, Reduction of Postoperative Facial Swelling by Low-Dose Methylprednisolone: An Experimental Study. Oral Maxillof ac Surg 51:987·991, 1993

7.        Blackwell G L, Carnuccio R, Rosa M, et al: Glucocorticoids induce: Glucocorticoids induce the formation and release of anti-inflammatory and antiphospholipase proteins into the peritoneal cavity of the rat. Br J Pharmacol 76:185, 1982 This article can be downloaded from www. ijpbs. net P – 12

8.        Hong SL, Levine L: Inhibition of arachidonic acid release from cells as the biochemical action of anti-inflammatory corticosteroids. Proc Natl Acad Sci USA 73: 1730, 1976

9.        Tam S, Hong SL, Levine L: Relationships among the steroids ofanti-inflammatory properties and inhibition of pros tagiandin production and arachidonic acid release by transformed mouse fibroblasts Pharmacol Exp Ther 203:162, 1977

10.      Anne Pedersen, Decadronphosphate" in the relief of complaints after third molar surgery A double-blind, controlled trial with bilateral oral surgery. Int. J. Oral Surg. 1985: 14: 235-240

11.      Hooley J R, Francis, f. H. : Betamethasone in traumatic oral surgery. J. Oral Surg, 1969: 27: 398-403.

12.      Skjelbred. P. & Lokken, P. : Post- operativepain and inflammatory reaction reduced by injection of a corticosteroid. A controlled trial in bilateral oral surgery. Eur. J. Clin. Pharmacol. 1982: 21: 391-396.

13.      Edward A. Neupert, Jesse W. Lee, christine b. Philput and john r. Gordon, evaluation of dexamethasone for of postsurgical sequelae of molar removal. J oral maxillofac surg 50:1177-1182. 1992

14.      Ong CK, Seymour RA. Pathogenesis of postoperative oral surgical pain. Anesth Prog 2003: 50: 5–17

15.      Alexander RE, Throndson RR. A review of perioperative corticosteroid use in dentoalveolar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000: 90: 406–415

16.      Beirne OR, Hollander B. The effect of methylprednisolone on pain, trismus, and-swelling after removal of third molars. Oral Surg Oral Med Oral Pathol 1986: 61: 134–138

17.      Messer EJ, Keller JJ. The use of intraoral dexamethasone after extraction of mandibular third molars. Oral Surg Oral Med Oral Pathol 1975: 40: 594– 598

18.      Milles M, Desjardins PJ. Reduction of postoperative facial swelling by low-dose methylprednisolone: an experimental study. J Oral Maxillofac Surg 1993: 51: 987–991.

 

 

Received on 20.07.2014          Modified on 13.08.2014

Accepted on 18.08.2014          © RJPT All right reserved