The surgical removal of mandibular third molar is a common procedure with inflammatory complications that included pain swelling and trismus. A range of meases to minimise these complications include analgesics, antibiotics, corticosteroids, cryotherapy, and platelet-rich plasma. A number of different corticosteroids care available and can be delivered, oral, intramuscularly, submucosally and intravenously and there is some evidence that they improve outcomes.
The aim of this review was to investigate the effectiveness of a single pre- operative dose of oral corticosteroids in reducing pain, trismus and oedema following surgical removal of lower third molars.
Methods
Searches were conducted in the Embase, Medline, DOSS, CINAHL and CENTRAL, Scopus, Clinicaltrials.gov and OpenGrey databases. Randomised controlled trials (RCTs) of the effects of ingle pre-operative dose of oral corticosteroids before lower third molar extractions were considered. Two reviewers independently screened and selected studies and extracted data. Risk of bias was assessed using the Cochrane risk of bias tool. A narrative summary of the findings was presented.
Results
- 4 RCTs involving a total of 212 patients were included.
- All 4 studies were considered to have unclear risk of bias.
- 8 mg dexamethasone 60-90 minutes before surgical extractions was tested in all 4 RCTs.
- 3 studies showed an improvement in the pain visual analogue scale (VAS) scores for dexamethasone which was not statistically significant for 2 studies. One study found no improvement.
- Only 1 study measured oedema and trismus finding no difference.
- 3 studies reported no complications 1 RCT reporting 1 episode of post-operative alveolar infection in the dexamethasone group and one occurrence of alveolar osteitis in the placebo group
Conclusions
The authors concluded: –
pre-operative oral administration of 8 mg of dexamethasone has little benefit to a patient undergoing lower third molar surgical extraction. There is insufficient evidence to establish the benefits of corticosteroids in the reduction of oedema and trismus. Furthermore, there is insufficient evidence to determine an association between the surgical time for lower third molar extraction and the use of corticosteroids.
Comments
A number of systematic reviews have looked at the use of corticosteroids in oral surgery procedures (Dental Elf – 17th Sep 2018, Dental Elf – 18th Nov 2015, Dental Elf – 5th Mar 2013, Dental Elf – 3rd Sep 2013). These earlier reviews address broader questions than this new review which focusses on the use of a single oral dose of corticosteroid pre-operatively. The authors have conducted and extensive literature search but only 4 RCTs met their inclusion criteria. The included RCTs have been assessed as being at unclear risk of bias although two of the RCTs were considered to be at high risk of bias for attrition and reporting bias. Although all 4 studies assessed pain using a visual analogue scale (VAS) no meta-analysis was conducted and only a narrative summary was presented. The authors concluded that there was little benefit to patients from pre-operative oral corticosteroids although a previous review (Dental Elf – 17th Sep 2018) had suggested that independent of administration route corticosteroids had a beneficial effect on pain and trismus. Future studies would benefit from following recognised international guidance in the conduct and reporting of studies and the use of common outcome sets to improve the quality of evidence and improve patient outcomes from this commonly performed surgical procedure.
Links
Primary Paper
Shibl M, Ali K, Burns L. Effectiveness of pre-operative oral corticosteroids in reducing pain, trismus and oedema following lower third molar extractions: a systematic review. Br Dent J. 2021 Jul 8. doi: 10.1038/s41415-021-3165-y. Epub ahead of print. PMID: 34239059.
Other references
Dental Elf – 17th Sep 2018
Third molar surgery: Steroids had a beneficial effect on pain, swelling and trismus
Dental Elf – 18th Nov 2015
Dexamethasone reduced pain and swelling following third molar surgery
Dental Elf – 5th Mar 2013
Dental Elf – 3rd Sep 2013
Picture Credits
“File:Impacted Wisdom Tooth aka Lower Left Third Molar 38 RVG IOPA Xray.jpg” by Nizil Shah is licensed under CC BY-SA 4.0
