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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 28  |  Issue : 2  |  Page : 105-110

Comparison of the clinical efficacy of methylprednisolone with ibuprofen and ibuprofen alone on the postoperative sequelae of surgical removal of impacted third molar


1 Department of Oral and Maxillofacial Surgery, Maharaj Ganga Singh Dental College and Research Institute, Sri Ganganagar, Rajasthan, India
2 Department of Oral and Maxillofacial Surgery, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab, India
3 Department of Oral and Maxillofacial Surgery, Kanti Devi Dental College, Mathura, Uttar Pradesh, India

Date of Web Publication20-May-2014

Correspondence Address:
Navneet Kaur
14-C, Model Town Patiala, Punjab - 147 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.132850

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  Abstract 

Purpose: The aim of the study was to compare the clinical efficacy of methylprednisolone with ibuprofen to ibuprofen alone on the postoperative sequelae of surgical removal of impacted third molars. Materials and Methods: The present study was conducted on the 35 patients requiring surgical extraction of bilateral impacted third molars attending the Outpatient Department of Oral and Maxillofacial Surgery, Guru Nanak Dev Dental College and Research Institute. The impacted teeth were removed in two sessions at least 3 weeks apart. The selected patients were randomly put on regimen 1 or regimen II at either the first or second surgery in accordance with randomization plan. The measurements and recordings for pain, swelling, and interincisal distance (mouth opening), were made on 1 st , 3 rd , and 7 th day postoperatively on the scales designed for the purpose. The data recorded was compiled and put to statistical analysis. Results: It was observed from the present study that postoperative sequelae, that is, pain, swelling, and trismus was significantly less in the regimen I group than regimen II group on the 1 st and 3 rd postoperative day. Conclusion: The results of this study substantiate the fact that a single class of drugs (nonsteroidal anti-inflammatory drug (NSAID)) is less effective in controlling postoperative inflammatory sequelae than the combination of ibuprofen (NSAID) and methylprednisolone (corticosteroid) following the third molar surgery. Therefore, this pharmaceutical combination should be considered for attenuation of postoperative sequelae in healthy patients undergoing surgical removal of impacted mandibular third molar.

Keywords: Bilateral impacted third molars, comparative research, postoperative sequelae, regimen I-methylprednisolone with ibuprofen, regimen II-ibuprofen alone


How to cite this article:
Kaur N, Misurya R, Narula R, Kumar M, Neelkamal, Neeraj. Comparison of the clinical efficacy of methylprednisolone with ibuprofen and ibuprofen alone on the postoperative sequelae of surgical removal of impacted third molar. Indian J Pain 2014;28:105-10

How to cite this URL:
Kaur N, Misurya R, Narula R, Kumar M, Neelkamal, Neeraj. Comparison of the clinical efficacy of methylprednisolone with ibuprofen and ibuprofen alone on the postoperative sequelae of surgical removal of impacted third molar. Indian J Pain [serial online] 2014 [cited 2019 Sep 17];28:105-10. Available from: http://www.indianjpain.org/text.asp?2014/28/2/105/132850


  Introduction Top


Surgical extraction of impacted third molar, one of the most commonly performed oral surgical procedure is associated with variable postoperative sequelae like pain, swelling, and trismus resultant of inflammatory response to tissue trauma. [1],[2]

Instituting active measures to minimize these postoperative sequelae and morbidity is an integral part of high quality oral surgical care. [3],[4],[5],[6],[7]

Clinical trials in oral surgery have supported the hypothesis that nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are effective in delaying and preventing many of these postoperative sequelae. The apparent interaction between the mechanisms of action of NSIADs and corticosteroids suggests that cotherapy may provide synergistic anti-inflammatory and analgesic effect in the absence of side effects. [1],[3],[8],[9]

The aim of the present study is to compare the efficacy of coadministered methylprednisolone-ibuprofen with ibuprofen alone, in the postoperative management of pain, swelling, and trismus following removal of impacted mandibular third molars.


  Materials and Methods Top


The present study was conducted on the 35 patients requiring surgical extraction of bilateral impacted third molars attending the Outpatient Department of Oral and Maxillofacial Surgery, Guru Nanak Dev Dental College and Research Institute, Sunam (Pb) The age and sex of the patients participated in the present study is shown in [Figure 1] and [Figure 2]. The diagnosis was made on the basis of history, clinical, and the radiological examination. Prior to surgery a brief history of every patient was taken to select cases as per inclusion and exclusion criteria.
Figure 1: Distribution of patients according to sex

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Figure 2: Distribution of patients according to age

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Following measurements were made for all the selected patients.



1. Facial swelling was determined by recording facial size postoperatively and comparing it with presurgical baseline measurements. The level of facial swelling was determined by a modification of tape measuring method of Gabka and Matsumara used by Schultze-Mosgau et al (1995). [8] Three measurements were [Figure 3]:
Figure 3: Markings for the measurement of facial swelling S1, S2, and S3

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S 1 - From the lateral canthus of the eye to the angle of the mandible.

S 2 - From the tragus to the outer corner of the mouth.

S 3 - From the tragus to pogonion.

2. Interincisal opening was evaluated by measuring the distance on maximal opening between the right maxillary and mandibular incisor with a vernier's caliper. [8]

3. Pain was recorded using non-caliberated 100 mm visual analogue scale (VAS). The end points of the scale were 'no pain' and 'pain could not be worse'. [8]

The impacted teeth were removed in two sessions at least 3 weeks apart. The selected patients were randomly put on regimen I or regimen II at either the first or second surgery in accordance with randomization plan.

Regimen I

  • Methylprednisolone sodium succinate 125 mg intravenous immediately before surgery, followed by two 8 mg tablets of oral methylprednisolone the evening after surgery, then 4 mg tablets every 6 h postoperatively on the 1 st and 2 nd postoperative day.
  • Tablets of ibuprofen 400 mg 1 h preoperatively and every 6 h postoperatively on the day of surgery and 1 st and 2 nd postoperative day.


Regimen II

  • Tablets of ibuprofen 400 mg orally 1 h preoperatively and every 6 h postoperatively the day of surgery and 1 st and 2 nd postoperative day.



  Observations and Results Top


The measurements and recordings for pain, swelling, and interincisal distance (mouth opening), were made on 1 st , 3 rd , and 7 th day postoperatively on the scales designed for the purpose. The data recorded was compiled and put to statistical analysis.

The patients were evaluated on following parameters.

Pain Mean Value of Pain on VAS [Table 1] with statistical analysis [Table 2].

The data was analysed statistically [Table 1] and [Table 2].

The mean difference in pain experienced by patients on regimen I and II was highly significant at 24 and 72 h, but nonsignificant on 7 th postoperative day.

Swelling

The mean values of swelling (S 1 , S 2 , and S 3 ) was measured preoperatively and then on the 1 st , 3 rd , and 7 th postoperative day [Table 3] and [Table 4].

The data was analysed statistically.

Mean Value of Facial swelling S 1 [Table 3] with statistical analysis [Table 4].

The mean difference in measured swelling (S 1 ) in patients on regimen I and II was highly significant at 24 and 72 h, but not significant on 7 th day [Table 5].

The data was analysed statistically [Table 6].

Mean Value of Facial swelling S 2 [Table 5] with statistical analysis [Table 6].

The mean difference in measured swelling (S 2 ) in patients on regimen I and II was highly significant at 24 and 72 h, but not significant on 7 th day [Table 7].

Mean Value of Facial swelling S 3 [Table 7] with statistical analysis [Table 8].

The data was analyzed statistically [Table 8].

The mean difference in measured swelling (S 3 ) in patients on regimen I and II was highly significant at 24 and 72 h, but not significant on 7 th day.

Trismus

The degree of trismus can be evaluated from maximum mouth opening (MMO) [Table 9].

Mean Value of maximum mouth opening [Table 9] with statistical analysis [Table 10].

The data was analyzed statistically [Table 10].
Table 1: Mean value of pain experienced by the patient on regimen I and II as recorded on visual analog scale (VAS)


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Table 2: t-test applied to analyze statistical


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Table 3: The mean value of facial swelling (S1: From the lateral corner of the eye to the angle of the mandible) measured in patients on regimen I and II


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Table 4: t-test applied to analyze statistical


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Table 5: The mean value of facial swelling (S2: From the tragus to the outer corner of the mouth) measured in patients on regimen I and II


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Table 6: t-test applied to analyze statistical


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Table 7: The mean value of facial swelling (S3: From the tragus to pogonion) measured in patients on regimen I and II


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Table 8: t-test applied to analyze statistical


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Table 9: The mean value of maximum mouth opening (MMO) in patients on regimen I and II


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Table 10: t-test applied to analyze statistical


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The mean difference in MMO between two groups was highly significant at 24 and 72 h, but nonsignificant on 7 th postoperative day.

It was observed from the present study that postoperative sequelae, that is, pain, swelling, and trismus was significantly less in the regimen I group than regimen II group on the 1 st and 3 rd postoperative day.


  Discussion Top


Surgical extraction of third molars results in an intense inflammatory response as with any surgical procedure that is characterized by edema, erythema, pain, rise in temperature, and loss of function. Most studies advocate the use of glucocorticoids along with NSAIDS for preventing postoperative pain, swelling, and trismus (Schultze-Mosgau et al., (1995); [8] Hyrkas et al., (1993); [10] Buyukkurt et al., (2006)). [11]

Corticosteroids must be administered at anti-inflammatory doses in excess of physiological concentrations released under normal condition and under conditions of stress. Methylprednisolone sodium succinate, a synthetic glucocorticoid is about five times as potent as hydrocortisone and also have shown to be of value in the reduction of postoperative sequelae (Esen et al., (1999)). [12]

Beirne and Hollander (1986) [13] and Gersema et al., (1992) [14] recommended the administration of a high-loading dose of 125 mg of methylprednisolone parenterally, that yielded the best results.

Corticosteroids for dentoalveolar surgery are available for oral, parenteral, and intramuscular use. The ideal route of administration is intravenous as it provides an immediate pharmacologic response, reduces patient noncompliance, and provides a more predictable response.

Postoperative edema peaks 48-72 h after surgery. As the half-life of methylprednisolone is 18-36 h. Its anti-inflammatory activity will not be effective if given as single dose. Rebound swelling can occur if the duration of use is inadequate; therefore, it is important to maintain levels of short-duration steroid formulations for more than 1 day. Alexander and Throndson (2000) [15] suggested alternative for this is to place the patient on multiple-day dosage regimen of oral corticosteroid 3 days after surgery. Tapering of doses is not mandatory in short-term dosing. In the present study, methylprednisolone 125 mg is used preoperatively through intravenous route and is maintained postoperatively through oral route by giving 16 mg methylprednisolone in the evening of surgery and 4 mg 6-hourly for 2 days as suggested by Alexander and Throndson (2000). [15]

Postsurgical facial edema is difficult to quantify accurately, since it requires a three-dimensional measurement with an irregular, convex surface, and can manifest itself internally as well as externally. Over the years, numerous researchers have tried various techniques in an effort to objectively measure edema, most of which are indirect assessments of the altered contours of skin surface, that is, visual analogue scales, standardized stereoradiographic or photographic measurements, computerized tomography, modified face bow devices, ultrasonography, facial plethysmographs, or various other means of taking direct facial measurements.

In the present study facial swelling was determined by a modification of the tape measuring method of Gabka and Matsumara as used by Schultze-Mosgau et al., (1995). [8] Although this method is not as accurate as computed tomography (CT) scan or magnetic resonance imaging (MRI) for making precise measurements of facial soft tissue volume; however, it is a noninvasive, simple, cost-effective, and time saving method, which provides numeric data for determination of soft tissue contour changes. Same method have been used by Ustun et al., (2003). [16]

In this study the mean increase in facial swelling (S 1 , S 2 , and S 3 ) in regimen I was significantly less than that of regimen II on 1 st and 3 rd postoperative day. Similar findings have been presented by Schultze-Mosgau et al., (1995). [8] Beirne and Hollander (1986) [13] noted decreased edema the 1 st day after surgery by using a single intravenous dose of 125 mg of methylprednisolone immediately before surgery, but they noted a rebound increase in edema on the 2 nd and 3 rd postoperative days, emphasize the need for a longer duration of dosing to extend the benefits of the drug throughout the period of edema formation.

In our study the mean pain score on VAS scale in regimen I (methylprednisolone-ibuprofen combination) was significantly less than that of regimen II (ibuprofen alone) on 1 st and 3 rd postoperative day. In studies by Hyrkas et al., (1993) [10] and Buyukkurt et al., (2006) [11] pain score was significantly less in glucocorticocoids-NSAID combination group than NSAID group only on the day of surgery; whereas in studies by Schultze-Mosgau et al., (1995) [8] and Bamgbose et al., (2005) [17] pain score was significantly less on the 1 st and 2 nd postoperative day. In the present study significant difference in the pain score is there even on the 3 rd postoperative day which may be because of continuation of corticosteroid administration on the 1 st and 2 nd postoperative days. Similar findings have been presented by Carriches et al., (2006). [18]

In this study the mean value of maximum mouth in regimen I was significantly more than that of regimen II on 1 st and 3 rd postoperative day. In the study of Schultze-Mosgau et al., (1995) [8] restriction in maximum mouth opening is significant less in methylprednisolone-ibuprofen combination group on the 1 st postoperative day when compared with ibuprofen group; whereas in the study by Esen et al., (1999) [12] result was significant on 2 nd postoperative day.


  Conclusion Top


The results of this study substantiate the fact that a single class of drugs (NSAID) is less effective in controlling postoperative inflammatory sequelae than the combination of ibuprofen (NSAID) and methylprednisolone (corticosteroid) following the third molar surgery.

Therefore, this pharmaceutical combination should be considered for attenuation of postoperative sequelae in healthy patients undergoing surgical removal of impacted mandibular third molar.

 
  References Top

1.Troullos ES, Hargreaves KM, Butler DP, Dionne RA. Comparison of non steroidal anti-inflammatory drugs, ibuprofen and flurbiprofen, with Methylprednisolone and placebo for acute pain, swelling and trismus. J Oral Maxillofac Surg 1990;48:945-52.  Back to cited text no. 1
    
2.White RP Jr, Shugars DA, Shafer DM, Laskin DM, Buckley MJ, Phillips C. Recovery after third molar surgery: Clinical and health-related quality of life outcomes. J Oral Maxillofac Surg 2003;61:535-44.  Back to cited text no. 2
    
3.Sisk AL, Bonnington GJ. Evaluation of methylprednisolone and flurbiprofen for inhibition of post-operative inflammatory response. Oral Surg Oral Med Oral Pathol 1985;60:137-45.  Back to cited text no. 3
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4.Bahn SL. Glucocorticosteroids in dentistry. J Am Dent Association 1982;105:476-81.  Back to cited text no. 4
    
5.Huffman GG. Use of methylprednisolone sodium succinate to reduce postoperative edema after removal of impacted third molars. J Oral Surg 1977;35:198-9.  Back to cited text no. 5
[PUBMED]    
6.Markiewicz M.R, Brady M.F, Ding E.L, Dodson TB. Corticosteroids reduce postoperative morbidity after third molar surgery: A systemic review and meta-analysis. J Oral Maxillofac Surg 2008;66:1881-94.  Back to cited text no. 6
    
7.Montgomery MT, Hogg JP, Roberts DL, Redding SW. The use of glucorticosteroids to lessen the inflammatory sequelae following third molar surgery. J Oral Maxillofac Surg 1990;48:179-187.  Back to cited text no. 7
    
8.Schultze-Mosgau S, Schmelzeisen R, Frolich JC, Schmele H. Use of Ibuprofen and Methylprednisolone for the prevention of pain and swelling after removal of impacted third molars. J Oral Maxillofac Surg 1995;53:2-7.  Back to cited text no. 8
    
9.Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and nonsteroidal antiinflammatory medication for the management of pain and inflammation after third molar surgery: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:630-40.  Back to cited text no. 9
    
10.Hyrkas T, Ylipaavalniemi P, Oikarinen VJ, Paakkari I. A Comparison of diclofenac with and without single dose intravenous steroid to prevent postoperative pain after third molar removal. J Oral Maxillofac Surg. 1993;51:634-6.  Back to cited text no. 10
    
11.Buyukkurt MC, Gungormus M, Kaya O. The effect of a single dose Prednisolone with and without diclofenac on pain, trismus and swelling after removal of mandibular third molars. J Oral Maxillofac Surg 2006;64:1761-6.  Back to cited text no. 11
    
12.Esen E, Tasar F, Akhan O. Determination of the anti-inflammatory effects of Methylprednisolone on the sequelae of third molar surgery. J Oral Maxillofac Surg 1999;57:1201-8.  Back to cited text no. 12
    
13.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;61:134-8.  Back to cited text no. 13
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14.Gersema L, Baker K. Use of corticosteroids in oral surgery. J Oral Maxillofac Surg 1992;50:270-7.  Back to cited text no. 14
    
15.Alexander RE, Throndson RR. A review of perioperative corticosteroid use in dentoalveolar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:406-15.  Back to cited text no. 15
    
16.Ustun Y, Erdogan O, Esen E, Karsli ED. Comparison of the effects of 2 doses of Methylprednisolone on pain, swelling, and trismus after third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:535-9.  Back to cited text no. 16
    
17.Bamgbose BO, Akinwande JA, Adeyemo WL, Ladeinde AL, Arotiba GT, Ogunlewe MO. Effects of co-administered Dexamethasone and Diclofenac potassium on pain, swelling and trismus following third molar surgery. Head Face Med 2005;1:11.  Back to cited text no. 17
    
18.López Carriches C, Martínez González JM, Donado Rodríguez M. Carriches CL, Martinez-Gonzalez JM, Rodriguez MD. The use of methylprednisolone versus diclofenac in the treatment of inflammation and trismus after surgical removal of lower third molars. Med Oral Patol Oral Cir Bucal 2006;11:E440-5.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]


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