Q U I N T E S S E N C E I N T E R N AT I O N A L
ORAL SURGERY
Clinical comparison of submucosal injection of
dexamethasone and triamcinolone acetonide on
postoperative discomfort after third molar surgery
Tamer Zerener, DDS, PhD1/Yavuz Sinan Aydintug, DDS, PhD2/Metin Sencimen, DDS, PhD3/Gurkan Rasit Bayar, DDS,
PhD3/Mahmut Yazici, MD4/Hasan Ayberk Altug, DDS, PhD3/Ahmet Ferhat Misir, DDS, PhD5/Cengizhan Acikel, MD6
Objective: The aim of the study was to compare the eect of
submucosal injection of dexamethasone and triamcinolone
acetonide on postoperative pain, swelling, and trismus occur-
ring after impacted mandibular third molar surgery. Method
and Materials: A total of 78 patients (aged 18 to 35) with
asymptomatic, unilateral, impacted mandibular third molar,
and without any systemic disease were included in this study.
Patients were divided into three groups randomly (control,
dexamethasone, and triamcinolone acetonide). In the experi-
mental groups, dexamethasone and triamcinolone acetonide
were injected into submucosa at about 1 cm above the surgical
area submucosally. The control group of patients did not take
any drug submucosally but the same surgical procedure was
applied. Pain evaluation was performed by visual analog scale
(VAS). Swelling was measured using a exible standard ruler
measuring the dimensions of the axes between certain points
on the face. For trismus evaluation, maximum mouth opening
Key words: submucosal dexamethasone, submucosal triamcinolone acetonide, third molar surgery
1
Specialist, Department of Oral and Maxillofacial Surgery, Gulhane Medical Acad-
emy, Etlik, Ankara, Turkey.
2 Professor, Department of Oral and Maxillofacial Surgery, Gulhane Medical Acad-
emy, Etlik, Ankara, Turkey.
3 Associate Professor, Department of Oral and Maxillofacial Surgery, Gulhane
Medical Academy, Etlik, Ankara, Turkey.
4 Specialist, Department of Endocrinology, Gulhane Medical Academy, Etlik,
Ankara, Turkey.
5
Associate Professor, Faculty of Dentistry, Bulent Ecevit University, Zonguldak, Turkey.
6 Associate Professor, Department of Biostatistics, Gulhane Medical Academy,
Etlik, Ankara, Turkey.
Correspondence: Dr Tamer Zerener, Department of Oral and Maxillofa-
cial Surgery, Gulhane Medical Academy, 06018 Etlik, Ankara, Turkey.
Email: dttz@mynet.com
VOLUME 46 NUMBER 4 APRIL 2015
Tamer Zerener
was measured. Measurements taken on the preoperative, and
on postoperative rst, third, and seventh days were compared
with each other and statistically evaluated. Results: There were
statistically signicant dierences between the control and
experimental groups on the dierent days of the postoperative
period. The eect of triamcinolone acetonide on pain started on
the rst day postoperatively and the eect of triamcinolone
acetonide on trismus and pain was better than other groups at
the third and seventh days. However, there was no statistically
signicant dierence between the eects of dexamethasone
and triamcinolone acetonide regarding postoperative compli-
cations. Conclusion: The submucosal injection of dexametha-
sone or triamcinolone acetonide might be an eective
treatment for postoperative discomfort occurring following
impacted mandibular third molar surgery, and triamcinolone
acetonide could be applied as an alternative to dexamethasone.
(Quintessence Int 2015;46:317326; doi: 10.3290/j.qi.a33281)
Third molar surgery can cause severe side effects such
as swelling (edema), pain, and trismus. Oral and maxil-
lofacial surgeons have attempted to eliminate these
side effects for decades. Various techniques and medi-
cations suggested in the literature have been used by
surgeons.1,2
Many authors have emphasized that the use of cor-
ticosteroids before or after the surgical procedure can
decrease the severity of postsurgical side effects.1-5 Sup-
pression of each stage of the inflammatory response
317
Q U I N T E S S E N C E I N T E R N AT I O N A L
Zerener et al
appears to be the major action of the corticosteroids.1
Different dosing regimens and application methods
can be used, but there is no consensus. In some studies,
single or multiple doses of corticosteroids were used
preoperatively through intravenous or oral routes in
third molar surgery.3-6 In addition, some authors evalu-
ated the effect of dexamethasone given postopera-
tively through either the alveolus or submucosal routes
for the prevention of inflammatory responses following
mandibular third molar surgery.7-9
The effect of submucosal and intramuscular injec-
tion of single dose dexamethasone (4 mg) immediately
following the surgical extraction of mandibular third
molars was investigated.9 It was suggested that dexa-
methasone (4 mg) given submucosally is an effective
way to minimize swelling, trismus, and pain after
removal of impacted mandibular third molars. It was
also stated that it offers a simple, safe, painless, non-
invasive, and cost-effective treatment for moderate and
severe patients.9
Triamcinolone acetonide (TA) is another glucocorti-
coid widely used on a chronic basis to treat severe
inflammatory diseases. Also, TA is a useful corticoste-
roid for intralesional injection as it has better local
potency, longer duration of action, and lower systemic
absorption.10 Submucosal administration of TA imme-
diately after third molar surgery could be an alternative
to dexamethasone given submucosally.
This study aims to evaluate and compare the effect
of dexamethasone and TA given submucosally on post-
operative edema, trismus, and pain after third molar
surgery.
METHOD AND MATERIALS
This clinical research was conducted at Gulhane Mili-
tary Medical Academy, Department of Oral and Maxil-
lofacial Surgery, between May 2011 and June 2012.
Clinical research design was approved by the Board of
Medical Ethics of the Institution (ethic committee num-
ber: 1491-1294-11/1539), and was conducted in accor-
dance with the Declaration of Helsinki. Patients were
given full written and verbal information about the
318
purpose of the investigation, and written informed
consent was obtained from all patients.
Before beginning the study, the sample size was
estimated using the G*Power Version 3.1.0 computer
program,11 using prevalence data published by Majid
and Mahmood.9 The power of the study was set at 80%
( = .20), with = .05 as the significance level. Based on
the above parameters, the estimated sample size per
group was 26.
Patients who were 18 years of age or older, without
any systemic disease (American Society of Anesthesiol-
ogy [ASA]-I), and had unilaterally impacted mandibular
third molars with Class II or III position and A, B, or C
impaction (Pell and Gregory classification)12 were
included in the study. Criteria for exclusion from the
study were:
presence of pericoronitis
allergy
pregnancy and breast-feeding
use of antibiotic or analgesic and/or anti-inflamma-
tory drug
taking any drug before the surgery.
Patients referred to the clinic for treatment were
divided into different groups consecutively. In the
dexamethasone (DEX) group (n = 26), 4 mg of dexa-
methasone (Onadron, IE Ulugay), and in the TA group
(n = 26), 4 mg of TA (Sinekort-A, IE Ulugay) was
instantly administered submucosally after surgery.
Patients in the control group (n = 26) did not receive
any corticosteroid drug. The surgeon and patients were
not blinded to test and to control medications.
Surgical protocol
Before the surgery, panoramic radiographs were taken
from patients to classify the impacted mandibular third
molars according to Pell and Gregory classification.12 All
surgical tooth extractions and measurements were
performed by same surgeon (TZ). The patients were
operated on under local anesthesia (articaine contain-
ing 1:100,000 epinephrine, Ultracaine DS, Aventis). Infe-
rior alveolar nerve block, lingual nerve block, and buc-
cal fold anesthesia by terminal infiltration were per-
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formed. A standardized surgical procedure was

undertaken in order to expose the cortical bone at the
buccal side of the third molar area by elevation of a tri-
angular full-thickness mucoperiosteal flap. Alveolot-
omy, and if necessary sectioning of the tooth, using a
round bur with handpiece under continuous sterile
saline solution was performed. The tooth was extracted
by elevators, and the bone levels were fixed. At the end
of the extraction, the socket wall was smoothed with a
Fig 1 Submucosal
bone ronguer, and irrigated with saline solution, then injection of the steroid.
the flap was sutured into the original position with 3/0
silk sutures. The surgical operation time (from incision
to the last suture) was recorded. Dexamethasone or TA
was injected immediately into the submucosa at about
1 cm above the surgical area (Fig 1), and the control
group of patients did not receive any drug submuco-
sally.
After all surgical procedures, routine postoperative
instructions and the same antibiotic therapy (amoxicil- B
lin and clavulanic acid, 1 g every 12 hours) were given
to the patients for 5 days. At the same time, A
paracetamol 500 mg were prescribed for as long as
rescue analgesia was necessary. A mouth rinse of chlor- C
hexidine was suggested for 5 days.
E
D
Data collection
Measurements were taken in a blinded manner by a
single clinical examiner preoperatively and on the first,
third, and seventh days of the postoperative period.
Fig 2 Tape-measure method for evaluation of facial swelling.
Swelling on the surgical side of the face was measured
using the tape measure method originally described by
Gabka and Matsumara13 and modified by Ordulu et al.14 each day. Trismus was evaluated by calculating the dif-
In this method, three different lines between five spe- ferences in maximal interincisal distances between the
cific points on the face were used. The points were: A, preoperative and on the first, third, and seventh post-
mid-point of the tragus; B, lateral canthus of the eye; C, operative days. Pain was evaluated on the operation
corner of the mouth; D, soft tissue pogonion; and E, day and the first, third, and seventh days of the postop-
angle of the mandible (Fig 2). The three lines were AC, erative period using a 100-mm-long visual analog scale
AD, and BE. The preoperative measurements of the (VAS) completed by the patients.
three lines were assumed as the baseline measure-
ments for each line. Differences between the baseline Data analysis
measurements of the three lines with the measure- Statistical analysis of the study was performed using
ments taken on the first, third, and seventh days of the SPSS (version 15.0, SPSS). Mean, median, maximum,
postoperative period showed the facial swelling for and minimum values were given as descriptive statis-

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Table 1 Patient data and variables

Variables Control group DEX group TA group Total P value*

Age (years; mean SD) 23.6 4.7 22.7 3.7 21.6 2.6 22.6 6.3 .358
Male 13 14 13 40
Sex .783
Female 13 12 13 38
Yes 11 9 10 30
Smoking .571
No 15 17 16 48
A 10 8 12 30
Position B 13 16 14 43 .815
C 3 2 0 5
CII 18 24 16 58
Relation/ramus .058
CIII 8 2 10 20
Duration of operation (min; mean SD) 17 4.4 18.8 5.6 16 4.8 17.2 5.0 .55
*Significant at P < .05.
DEX, dexamethasone given submucosally; SD, standard deviation; TA, triamcinolone acetonide given submucosally.

tics. Comparisons between the three groups were ana- RESULTS

lyzed by Kruskal-Wallis analysis of variance (ANOVA) or
chi-square tests, as appropriate. Comparisons between
the paired groups on the first, third, and seventh days
were performed by Mann Whitney U test. P values of
more than .05 were considered not significant. Due to
Bonferroni correction (P/number of comparison), at the
paired group comparisons, P values of more than .017
were considered not significant.
Cohen f effect sizes were calculated using G*Power
program for comparisons between several indepen-
dent groups. For the procedures provided by G*Power
3, the effect size f as defined by Cohen15 is used. In a
one-way ANOVA the effect size drawer can be used to
compute f from the means and group sizes of k groups
and a standard deviation common to all groups. For
tests of effects in factorial designs, the effect size
drawer offers the possibility to compute the effect size
f from the variance explained by the tested effect and
the error variance. Cohen defines f = 0.1, f = 0.25, and
f = 0.4 as small, medium, and large effects, re-
spectively.
For t test, Cohens d is used as effect size indices.
Cohen defines d = 0.2, d = 0.5, and d = 0.8 as small,
medium, and large effects, respectively.
In total, 78 patients (38 female and 40 male) requiring
removal of an impacted mandibular third molar partici-
pated in the study. Ages varied from 18 to 35 years
(mean age 22.6 6.3). Patient data, groups, and variables
are summarized in Table 1. There were no significant dif-
ferences (associated with age, sex, smoking, duration of
operation, and tooth position) among the groups.
Except for wound dehiscence reported by a few patients,
no serious complications or side effects were reported.
Surgical area healing was uneventful in all patients.
Facial swelling
In all groups, facial swelling increased on the first day
after surgery, and facial contour began to return to
normal at the end of the seventh day. Postoperative
edema was lower in DEX and TA groups than the con-
trol in all intervals. On the first, third, and seventh post-
operative days, Kruskal-Wallis test showed statistically
significant differences among the groups in all intervals
(P < .05) (Table 2, Fig 3). After that, comparisons were
made between the paired groups with Mann-Whitney
U test. There were statistically significant differences
between the control and other groups (P < .017) but
there was no statistically significant difference between
DEX and TA groups (P > .017) in all intervals (Table 3).

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Table 2 Comparison between the groups using Kruskal-Wallis ANOVA tests

Control group DEX group TA group

Cohen
Mean Mean Mean P effect
Variables SD Median MinMax SD Median MinMax SD Median MinMax value size
4.03 1.71 2.13
Day 1 3.69 1.609.60 1.40 0.604.60 1.86 0.204.40 < .001* 0.82
1.63 1.02 1.22
Swelling 2.10 0.83 1.03
Day 3 1.89 0.706.40 0.59 0.004.90 0.85 0.003.20 < .001* 0.57
(mm) 1.21 0.90 0.72
0.43 0.22 0.08
Day 7 0.28 0.001.10 0.0 0.002.70 0.0 0.005.50 < .001* 0.41
0.32 0.51 0.10
24.19 11.50 15.76
Day 1 21.00 0.0062.00 5.00 0.0044.00 8.00 0.0094.00 .009* 0.29
17.75 13.51 21.03
Pain 14.50 3.88 3.30
Day 3 10.00 0.0072.00 0.00 0.0028.00 0.00 0.0017.00 < .001* 0.71
(VAS) 15.86 7.06 4.85
2.38 1.23 0.42
Day 7 2.00 0.0010.00 0.00 0.0011.00 0.00 0.008.00 .001* 0.32
3.11 3.01 1.65
18.80 9.23 9.19
Day 1 21.00 32.000.01 5.00 28.000.00 7.50 23.000.00 < .001* 0.58
9.14 8.95 7.43
Trismus 14.15 7.03 6.69
Day 3 15.50 32.000.00 5.00 27.000.00 5.00 20.000.00 .001* 0.50
(mm) 9.10 7.75 6.72
7.15 3.46 2.53
Day 7 6.00 20.000.00 0.00 25.000.00 0.00 14.000.00 .012* 0.38
6.63 6.24 3.90
*Significant at P < .05.
DEX, dexamethasone given submucosally; SD, standard deviation; TA, triamcinolone acetonide given submucosally; VAS, visual analog scale.

Pain 6
The Kruskal-Wallis test showed statistically significant Control
5 TA
differences among the groups in all intervals (P < .05) DEX
4
Swelling (mm)

(Table 2, Fig 4). For the postoperative first day, Mann-

Whitney U test showed a statistically significant differ- 3
ence between the control and DEX groups (P < .017); 2
on the other hand, there were no statistically signifi- 1
cant differences between the control and TA groups,
0
and DEX and TA groups (P > .017) (Table 4). On the
1
postoperative third day, there was no statistically sig- 1 3 7
Days
nificant difference between TA and DEX groups
(P > .017); however, there were statistically significant Fig 3 Assessment of swelling (mean standard deviation).

differences between the control and DEX groups, and

the control and TA groups (P < .017). At the postopera-
tive seventh day, Mann-Whitney U test showed no
statistically significant difference between the control
and DEX groups, and DEX and TA groups (P > .017);
however, it showed a statistically significant difference
between the control and TA groups (P < .017).
Trismus
Postoperative trismus was evaluated with ANOVA test.
Statistically significant differences in maximal interinci-
sal distance were noted among the groups at the first,
third, and seventh postoperative days (P < .05) (Table 2,
Fig 5). The paired groups were compared with Mann-
Whitney U test. There were significant differences

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Table 3 Comparison between the paired groups on first, third, and seventh postoperative days with Mann-
Whitney U test in terms of swelling

Swelling (mm)
Postoperative
day Group Mean SD Median MinMax P value* Cohen effect size
Control 4.0 1.6 3.69 1.69.6
< .001* 1.7
DEX 1.7 1.0 1.40 0.64.6
Control 4.0 1.6 3.69 1.69.6
1 < .001* 1.34
TA 2.1 1.2 1.86 0.24.4
DEX 1.7 1.0 1.40 0.64.6
.24 0.36
TA 2.1 1.2 1.86 0.24.4
Control 2.1 1.2 1.89 0.76.4
< .001* 1.22
DEX 0.8 0.9 0.59 0.04.9
Control 2.1 1.2 1.89 0.76.4
3 < .001* 1.12
TA 1.0 0.7 0.85 0.03.2
DEX 0.8 0.9 0.59 0.04.9
.20 0.24
TA 1.0 0.7 0.85 0.03.2
Control 0.4 0.3 0.28 0.01.1
.001* 0.49
DEX 0.2 0.5 0.00 0.02.7
Control 0.4 0.3 0.28 0.01.1
7 < .001* 1.34
TA 0.08 0.1 0.00 0.05.5
DEX 0.2 0.5 0.00 0.02.7
.96 0.27
TA 0.08 0.1 0.00 0.05.5
*Significant at P < .017.
DEX, dexamethasone given submucosally; SD, standard deviation; TA, triamcinolone acetonide given submucosally.

50 difference between the control and TA groups

Control
(P > .017); however, there were no statistically signifi-
Visual Analog Scale (mm)

TA
40 DEX cant differences between the control and DEX, and DEX
30 and TA groups (P > .017) (Table 5).
20

10 DISCUSSION
0 The removal of mandibular third molars is one of the
most frequently performed procedures in oral and max-
-10
1 3 7 illofacial surgery.16 Extraction of impacted third molar
Days
involves trauma to the soft tissues and bony structures
Fig 4 Pain (VAS) assessment (mean standard deviation).
of the oral cavity resulting in pain and swelling.17 A num-
ber of studies have been conducted to evaluate the
between the control and other groups (P > .017) but efficacy of corticosteroids in reducing the postsurgical
there was no statistically significant difference between sequelae experienced after oral surgical procedures,
DEX and TA groups (P > .017) at the first and third post- particularly after the removal of impacted third molar
operative days. At the seventh postoperative day, teeth. In the late 1940s, synthetic cortisone derivates
Mann-Whitney U test showed a statistically significant called synthetic corticosteroids were synthesized for

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Table 4 Comparison between the paired groups on first, third, and seventh postoperative days with Mann-
Whitney U test in terms of pain

Pain (VAS) (mm)

Postoperative
day Group Mean SD Median MinMax P value* Cohen effect size
Control 24.19 17.75 21.00 0.0062.00
.004* 0.74
DEX 11.50 13.51 5.00 0.0044.00
Control 24.19 17.75 21.00 0.0062.00
1 .021 0.46
TA 15.76 21.03 8.00 0.0094.00
DEX 11.50 13.51 5.00 0.0044.00
.707 0.22
TA 15.76 21.03 8.00 0.0094.00
Control 14.50 15.86 10.00 0.0072.00
< .001* 0.81
DEX 3.88 7.06 0.00 0.0028.00
Control 14.50 15.86 10.00 0.0072.00
3 < .001* 1.01
TA 3.30 4.85 0.00 0.0017.00
DEX 3.88 7.06 0.00 0.0028.00
.856 0.16
TA 3.30 4.85 0.00 0.0017.00
Control 2.38 3.11 2.00 0.0010.00
.028 4.02
DEX 1.23 3.01 0.00 0.0011.00
Control 2.38 3.11 2.00 0.0010.00
7 .001* 0.80
TA 0.42 1.65 0.00 0.008.00
DEX 1.23 3.01 0.00 0.0011.00
.217 0.33
TA 0.42 1.65 0.00 0.008.00
*Significant at P < .017.
DEX, dexamethasone given submucosally; SD, standard deviation; TA, triamcinolone acetonide given submucosally; VAS: visual analog scale.

therapeutic purposes. These products rapidly found 30

Difference in Interincisal Distance

their way into the world of sports, in particular because Control

25 TA
of their anti-inflammatory properties.18 Glucocorticoids DEX

are capable of suppressing the inflammatory process 20

through numerous pathways.19 These anti-inflammatory 15

effects include inhibition of early processes such as 10
edema, fibrin deposition, capillary dilatation, movement 5
of phagocytes into the area, and phagocytic activities.
0
Later processes, such as capillary production, collagen
deposition, and keloid formation also are inhibited by -5
1 3 7
corticosteroids.20 A review of the literature reveals stud- Days

ies that have used methylprednisolone, betamethasone, Fig 5 Trismus assessment (mean standard deviation).

and dexamethasone at various dosages and administra-

tions. Dexamethasone is especially widely used in third
molar surgical procedures for its anti-inflammatory
action, and various doses of dexamethasone have been
used in most of the previous studies.7-9,21 The biologic
half-life of dexamethasone is 36 to 54 hours, and it is
considered to be a long-acting steroid. The most com-
monly used agents are oral dexamethasone (Decadron),
and intravenous or intramuscular dexamethasone
sodium phosphate (Decadron phosphate).1 TA is a better
corticosteroid for intralesional injection due to its better

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Table 5 Comparison between the paired groups on first, third, and seventh postoperative days with Mann-
Whitney U test in terms of trismus

Trismus interincisal distance (mm)

Postoperative
day Group Mean SD Median MinMax P value* Cohen effect size
Control 18.80 9.14 21.00 32.001.00
< .001* 1.06
DEX 9.23 8.95 5.00 28.000.00
Control 18.80 9.14 21.00 32.001.00
1 < .001* 1.16
TA 9.19 7.43 7.50 23.000.00
DEX 9.23 8.95 5.00 28.000.00
1.000 0.01
TA 9.19 7.43 7.50 23.000.00
Control 14.15 9.10 15.50 32.000.00
.005* 0.85
DEX 7.03 7.75 5.00 27.000.00
Control 14.15 9.10 15.50 32.000.00
3 .003* 0.94
TA 6.69 6.72 5.00 20.000.00
DEX 7.03 7.75 5.00 27.000.00
.986 0.04
TA 6.69 6.72 5.00 20.000.00
Control 7.15 6.63 6.00 20.000.00
.058 0.58
DEX 3.46 6.24 0.00 25.000.00
Control 7.15 6.63 6.00 20.000.00
7 .013* 0.87
TA 2.53 3.90 0.00 14.000.00
DEX 3.46 6.24 0.00 25.000.00
.830 0.19
TA 2.53 3.90 0.00 14.000.00
*Significant at P < .017.
DEX, dexamethasone given submucosally; SD, standard deviation; TA, triamcinolone acetonide given submucosally.

local potency, longer duration of action, and lower sys-
temic absorption. TA is a synthetic and long-acting cor-
ticosteroid widely used to treat severe inflammatory
diseases. For example, in the field of ophthalmology, TA
is widely used to treat uveitis, cystoid macular edema,
proliferative vitreoretinopathy, and choroidal neovascu-
lar membrane secondary to age related macular degen-
eration.22 The biologic half-life of parenterally adminis-
tered TA is 18 to 36 hours,23 whereas the mean elimina-
tion half-life in nonvitrectomized eyes is 18.6 days.24
TA is also applied clinically as a therapeutic agent to
treat multiple sclerosis, which is characterized by multi-
topic inflammation and demyelination.25 Meanwhile, it
has been widely accepted that topical (intralesional
injection) glucocorticoids (such as TA) are the mainstay
treatment for erosive oral lichen planus.26,27
Systemic and topical glucocorticoids are contraindi-
cated in patients with ocular primary glaucoma, tuber-
culosis, herpes simplex, or acute psychosis. Other condi-
tional contraindications include diverticulitis, Cushings
syndrome, active or latent peptic ulcer, hypertension,
renal insufficiency, diabetes mellitus, osteoporosis, and
acute or extended infections.28 In light of these undesir-
able effects, the risk-benefit ratio of glucocorticoid use
should be considered before application.29 In the pres-
ent study, no systemic or local complications such as
necrosis, atrophy, hypopigmentation, telangiectasia, or
incomplete healing after the submucosal administra-
tion of corticosteroids were encountered. This result
may be related to the single and low dose application of
steroid in the present study.
Graziani et al7 investigated different dosages and
application methods of dexamethasone (10 mg as sub-
mucosal injection regime, 4 mg and 10 mg as endo-
alveolar powder) on postoperative swelling, pain, and
trismus after bilateral surgical extraction of mandibular
third molars in 43 patients. In another study, Grossi et
al8 investigated the effects of different doses (4 mg and

324 VOLUME 46 NUMBER 4 APRIL 2015


8 mg) of dexamethasone given submucosally, on post-
operative swelling, pain, and trismus after mandibular
third molar surgery in 61 patients. Statistical analyses of
their investigations showed a reduced postoperative
degree of edema for the steroid groups compared with
the control group, especially on the postoperative sec-
ond day. They also stated that the submucosal injection
of dexamethasone reduced neither trismus nor the
subjects sense of pain compared with the control
group.7,8 It was suggested that despite corticosteroids
being effective in reducing postoperative edema, they
alone do not have a direct effect on pain.30,31
In contrast to the studies by Graziani et al7 and
Grossi et al,8 the present study found that there were
statistically significant differences between steroid and
control groups regarding postoperative pain. Statisti-
cally significant differences were present between DEX
and control groups on the postoperative first day, and
between TA and control groups on the postoperative
seventh day. However, for the assessment of pain there
were no statistically significant differences between
DEX and TA groups on the first, third, and seventh post-
operative days. As reported in a previous study,9 results
of the present study showed significantly less pain in
the steroid groups compared to the control group at all
intervals. This could be due to the method of applica-
tion. Furthermore, no nonsteroidal anti-inflammatory
drugs were prescribed, because this might affect the
study results. Instead, only rescue analgesic containing
paracetamol was prescribed.
On the other hand, some previous studies on dexa-
methasone reported a significant decrease in postop-
erative pain in the study groups that were given dexa-
methasone.32,33 Majid and Mahmood9 researched
submucosal and intramuscular injections of 4 mg dexa-
methasone on postoperative sequelae following man-
dibular third molar surgery. They evaluated the facial
swelling, trismus, and pain (VAS and rescue analgesic
tablets) at 1, 3, and 7 days postoperatively. Their results
showed that there was no significant difference
between the dexamethasone groups at any interval,
and both dexamethasone groups showed a significant
reduction in swelling compared with the control group.
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Zerener et al
Evaluation of the trismus showed a significant differ-
ence between the submucosal dexamethasone and the
control on the first day, but there were no significant
differences among the groups on the third and seventh
days. Pain (VAS) assessment indicated significant differ-
ences between dexamethasone and control groups at
all intervals, except for the intramuscular application on
the first day. In addition, evaluation of the effect of res-
cue analgesic tablets showed the same result using VAS.
Many authors have evaluated the use of dexameth-
asone with different application methods and dosages
for discomfort (edema, trismus, and pain) after third
molar surgery.7-9,34 The submucosal use of dexametha-
sone has been reported as an effective way to reduce
edema after third molar surgery.7-9 In agreement with
Majid and Mahmood,9 the present study showed that
the submucosal use of dexamethasone (4 mg) resulted
in a significant decrease in edema, and no statistically
significant differences were observed between the two
steroid groups and the control group on the first, third,
and seventh postoperative days. The present results
also indicated that the use of submucosal dexametha-
sone is more effective than submucosal TA on the first
and third postoperative days. However, TA was more
effective regarding edema on the seventh postopera-
tive day, which could result from the different half-life
of each steroid.
In the present study, evaluation of postoperative
trismus showed no statistically significant differences
between the steroid groups on postoperative days 1, 3,
and 7. In contrast to previous studies,7,8 the TA group
showed a significant difference compared to the control
group in the postoperative period. In line with the study
by Majid and Mahmood,9 the DEX group showed no
significant difference compared with the control group
on the seventh postoperative day. Conversely, the TA
group showed a significant difference compared with
the control group on the seventh postoperative day.
As well as the statistically significant results
between the control and study groups, submucosal
injection of dexamethasone and TA was observed to be
effective at increasing patients postoperative comfort
after third molar surgery.
325
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Zerener et al
In conclusion, these results support previous studies
that used submucosal application of dexamethasone to
reduce postoperative discomfort after third molar sur-
gery. The submucosal application of corticosteroid
drugs might be a relatively painless, comfortable, less
invasive method for the patient and surgeon. It is also
an effective, easy, and cheap method and its systemic
effect is limited. Furthermore, the present study
showed that administration of submucosal dexametha-
sone and TA produced similar effects in reducing
edema, pain, and trismus after third molar surgery. It
was concluded that the submucosal injection of dexa-
methasone or TA might be an effective treatment for
postoperative discomfort occurring following impacted
mandibular third molar surgery, and that TA could be
used as an alternative to dexamethasone. In addition,
future studies with different steroid drugs at different
dosages might be useful to obtain more dependable
evidence and reduce side effects.
REFERENCES
1. Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and
nonsteroidal antiinammatory medication for the management of pain and
inammation after third molar surgery: A review of the literature. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2009;107:630640.
2. Beirne OR, Hollander B, Francisco S. The eect of methylprednisolone on pain,
trismus, and swelling after removal of third molars. Oral Surg Oral Med Oral
Pathol 1986;61:134138.
3. Neupert EA, Lee JW, Philput CB, et al. Evaluation of dexamethasone for reduc-
tion of postsurgical sequelae of third molar removal. J Oral Maxillofac Surg
1992;50:11771182.
4. Esen E, Tasar F, Akban O. Determination of the anti-inammatory eects of
methylprednisolone on the sequelae of third molar surgery. J Oral Maxillofac
Surg 1999;57:12011206.
5. Elhag M, Coghlan K, Christmas P, Harvey W, Harris M. The antiinammatory
eects of dexamethasone and therapeutic ultrasound in oral surgery. Br J Oral
Maxillofac Surg 1985;23:1723.
6. Milles M, Desjardins PJ. Reduction of postoperative facial swelling by low dose
methylprednisolone: An experimental study. J Oral Maxillofac Surg
1993;51:987991.
7. Graziani F, DAiuto F, Arduino PG, Tonelli M, Gabriele M. Perioperative dexa-
methasone reduces post-surgical sequelae of wisdom tooth removal. A split-
mouth randomized double-masked clinical trial. Int J Oral Maxillofac Surg
2006;35:241246.
8. Grossi GB, Maiorana C, Garramone RA, et al. Eect of submucosal injection of
dexamethasone on postoperative discomfort after third molar surgery: a
prospective study. J Oral Maxillofac Surg 2007;65:22182226.
9. Majid OW, Mahmood WK. Eect of submucosal and intramuscular dexa-
methasone on postoperative sequelae after third molar surgery: comparative
study. Br J Oral Maxillofac Surg 2011;49:647652.
10. Hamner JE 3rd, Looney DD, Chused TM. Submucous brosis. Oral Surg Oral
Med Oral Pathol 1974;37:412421.
326
11. Erdfelder E, Faul F, Buchner A. A general power analysis program. Behav Res
Methods Instrum Comput 1996;28:111.
12. Pell GJ, Gregory BT. Impacted mandibular third molars: classication and
modied techniques for removal. Dental Digest 1933;39:330338.
13. Gabka J, Matsumura T. Measuring techniques and clinical testing of an anti-
inammatory agent (tantum) (in German). Munch Med Wochenschr
1971;113:198203.
14. Ordulu M, Aktas I, Yalcin S, et al. Comparative study of the eect of tube drain-
age versus methyleprednisolone after third molar surgery. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2006;101:e96e100.
15. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ:
Lawrence Erlbaum Associates, 1988.
16. Poeschl PW, Eckel D, Ellen P. Postoperative prophylactic antibiotic treatment
in third molar surgery: a necessity? J Oral Maxillofac Surg 2004;62:38.
17. Koerner KR. The removal of impacted third molars. Principles and procedures.
Dent Clin North Am 1994;38:255278.
18. Pujos E, Flament-Waton MM, Paisse O, Grenier-Loustalot MF. Comparison of
the analysis of corticosteroids using dierent techniques. Anal Bioanal Chem
2005;381:244254.
19. Kahn CM. The Merck Veterinary Manual, 9th ed. Whitehouse Station: Merck &
Co, 2005:2128.
20. Thomson/Micromedex. Drug Information for the Health Care Professional.
Volume 1. Greenwood Village: Thomsom, 2007:919.
21. Antunes AA, Avelar RL, Martins Neto EC, Frota R, Dias E. Eect of two routes of
administration of dexamethasone on pain, edema, and trismus in impacted
lower third molar surgery. Oral Maxillofac Surg 2011;15:217223.
22. Kim H, Csaky KG, Gravlin L, et al. Safety and pharmacokinetics of a preserva-
tive-free triamcinolone acetonide formulation for intravitreal administration.
Retina 2006;26:523530.
23. Gilman G. The Pharmacologic Basis of Therapeutics. 10th edition. New York:
McGraw-Hill, 2001.
24. Beer PM, Bakri SJ, Singh RJ, Liu W, Peters GB 3rd, Miller M. Intraocular concen-
tration and pharmacokinetics of triamcinolone acetonide after a single intra-
vitreal injection. Ophthalmology 2003;110:681686.
25. Abu-Mugheisib M, Benecke R, Zettl UK. Repeated intrathecal triamcinolone
acetonide administration in progressive multiple sclerosis: a review. Mult Scler
Int 2011;2011:219049.
26. Carbone M, Goss E, Carrozzo M, et al. Systemic and topical corticosteroid
treatment of oral lichen planus: a comparative study with long-term follow-
up. J Oral Pathol Med 2003;32:323329.
27. Thongprasom K, Luengvisut P, Wongwatanakij A, Boonjatturus C. Clinical
evaluation in treatment of oral lichen planus with topical uocinolone ace-
tonide: a 2-year follow-up. J Oral Pathol Med 2003;32:315322.
28. Williamson LW, Lorson EL, Osborn DB. Hypothalamic-pituitary-adrenal sup-
pression after short-term dexamethasone therapy for oral surgical procedure.
J Oral Surg 1980;38:2028.
29. Gersema L, Baker K. Use of corticosteroids in oral surgery. J Oral and Maxillofac
1992;50:270277.
30. Milles M, Desjardins PJ. Reduction of postoperative facial swelling by low-
dose methylprednisolone: an experimental study. J Oral Maxillofac Surg
1993;51:987991.
31. Dionne RA, Gordon SM, Rowan J, Kent A, Brahim JS. Dexamethasone sup-
presses peripheral prostanoid levels without analgesia in a clinical model of
acute inammation. J Oral Maxillofac Surg 2003;61:9971003.
32. Markovic A, Todorovic L. Eectiveness of dexamethasone and low-power
laser in minimizing oedema after third molar surgery: a clinical trial. Int J Oral
Maxillofac Surg 2007;36:226229.
33. Schmelzeisen R, Frolich JC. Preventive of postoperative swelling and pain by
dexamethasone after operative removal of impacted third molar teeth. Eur J
Clin Pharmacol 1982:44:275277.
34. Messer E, Keller J. The use of intraoral dexamethasone after extraction of
mandibular third molars. Oral Surg Oral Med Oral Pathol 1975;40:594598.
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