Indian Journal of Pain

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


Navneet Kaur1, Rajat Misurya1, Ravi Narula2, Munish Kumar2, Neelkamal2, Neeraj3,  
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

Correspondence Address:
Navneet Kaur
14-C, Model Town Patiala, Punjab - 147 001
India

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.



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;28:105-110


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 Dec 14 ];28:105-110
Available from: http://www.indianjpain.org/text.asp?2014/28/2/105/132850


Full Text

 Introduction



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



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}{Figure 2}

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}

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



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}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}{Table 10}

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



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



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.

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