Removal of third molars is a very commonly performed operation and the post-operative period is often associated with pain, swelling and trismus. Steroidal and non-steroidal anti-inflammatory drugs have been widely used to control post-operative pain and swelling. A number of trials and reviews of the use of corticosteroids to manage these common post-operative problems have been undertaken.
The aim of this review was to assess the effectiveness of corticosteroids in the post-operative control of pain swelling and trismus after third molar surgery.
Methods
Searches were conducted in the Medline/PubMed, Scopus and Cochrane Library databases. This was supplemented by hand searches of the journals; International Journal of Oral and Maxillofacial Surgery; Journal of Oral and Maxillofacial Surgery; British Journal of Oral and Maxillofacial Surgery; and Journal of Cranio-Maxillo-Facial Surgery. English language randomised controlled trials (RCTs) in patients undergoing third molar surgery and investigating pain swelling or trismus that compared any type of corticosteroid to placebo were considered. Two reviewers independently selected studies, with one reviewer extracting data which was checked by the second reviewer. Risk of bias was assessed using the Cochrane tool and meta-analyses conducted.
Results
- 17 studies involving a total of 730 patients were included.
- 11 studies used long-duration corticosteroids (dexamethasone 9 studies, betamethasone 2)
- 6 studies used medium duration corticosteroids (methylprednisolone 5 studies, prednisolone 1).
- Pain
- 15 studies evaluated using a visual analogue scale (VAS), 1 study the number of rescue medication.
- 13 studies demonstrated a positive effect on pain compared to placebo.
- 8 studies contributed to a meta-analysis
- Independent of the drug used 24 hours after surgery, a statistically significant difference was found in favour of corticosteroids. Mean Difference (MD) = 17.38 (95%CI; 24.81 to 9.95) [P = 0.002].
- At 7 days a favourable difference was only only found for methyl- prednisolone, MD = 9.57(95%CI; 14.33 to 4.82) [P < 0.0001].
- At 24 hours postoperative and independent of the time of administration (preoperative or postoperative), corticosteroids demonstrated significantly better results in comparison to the placebo MD =17.51 (95%CI; 24.96 to 10.07)[P < 0.00001].
- However, at 7 days post-op a statistically significant difference was only noted when corticosteroids were administered in the postoperative period, MD = 8.93 (95%CI; 13.94 to 3.92)[ P = 0.0005].
- Independent of the route of administration, the corticosteroids demonstrated significantly better results in comparison to the placebo at 24hours, MD = 17.51(95%CI; 24.96 to 10.07)[ P<0.00001]. At 7 days, only oral administration had a significantly better performance in comparison to the placebo, MD = 9.57(95%CI; 14.33 to 4.82) [P < 0.0001].
- Trismus
- 11 studies demonstrated a positive effect, 4 studies found no difference.
- 8 studies contributed to the meta-analysis.
- A significant difference favouring the corticosteroids was found with regard to inter-incisal distance at 48–72 hours after surgery, MD = 6.10(95%CI; 3.42 to 8.77) and at the day 7 evaluation MD = 2.51(95%CI; 1.74 to 3.28).
- For time of administration, preoperative administration of the corticosteroids performed better than placebo at 48–72 hours, MD = 5.58(95%CI; 2.96 to 8.20) no difference was seen with postoperative administration MD = 6.35(95%CI; 0.76 to 13.45).
- At 7 days, corticosteroids performed better than the placebo independent of the time of administration, MD = 2.51(95%CI; 1.74 to 3.28).
- Fot route of administration, both oral and parenteral administration demonstrated significantly better results in comparison to the placebo at 48–72 hours, MD = 6.26(95% CI 3.56 to 8.96) and at 7 days MD = 2.51(95%CI; 1.74 to 3.28).
- Swelling
- 14 studies found a positive effect for corticosteroids on swelling., 2 studies no difference.
- Meta-analysis was not possible due to study heterogeneity.
Conclusions
The authors concluded: –
The use of corticosteroids had a positive effect with regard to the control of the pain, oedema, and trismus associated with the surgical removal of impacted mandibular third molars in the majority of studies included in this systematic review. With the exception of the submucosal route, the route of administration did not seem to influence the results, making the oral route an easy and excellent option. The administration of a corticosteroid in the preoperative phase was superior to its use in the postoperative phase for the control of trismus.
Comments
We have previous looked at reviews of this topic in 2015 and 2012 (Dental Elf – 18th Nov 2015 and 3rd Sep 2012) and it has been the focus of other reviews. While this new review has searched 3 major databases the decision made to restrict included studies to those published in English means that relevant studies may have been excluded. 17 RCTs were included with the analysis finding a positive effect from corticosteroids on pain swelling and trismus. A better effect for trismus being demonstrated with pre-operative administration. Meta-analysis for the facial swelling outcome could not be conducted due to the difficulty of and variation in assessment of this parameter.
The meta-analysis conducted demonstrated a high degree of heterogeneity this was considered to be due to the variation in steroid dosages used in the different studies. Consequently, further high-quality studies to help identify the best dosage regimens would be helpful. While an overall risk of bias table is presented in the main paper details for the individual studies were not. The authors highlighted high risk of bias in some studies in relation to allocation concealment, incomplete outcomes assessment and selective reporting. While the majority of the included studies used single dosages of corticosteroids prolonged use is associated with adverse effects and can be seen even in short-term. However, there was no mention of adverse effects in the included studies and these should be noted in future studies.
Links
Primary Paper
Almeida RAC, Lemos CAA, de Moraes SLD, Pellizzer EP, Vasconcelos BC. Efficacy of corticosteroids versus placebo in impacted third molar surgery: systematic review and meta-analysis of randomized controlled trials. Int J Oral Maxillofac Surg. 2018 Jun 22. pii: S0901-5027(18)30199-1. doi: 10.1016/j.ijom.2018.05.023. [Epub ahead of print] Review. PubMed PMID: 29941229.
Other references
Dental Elf – 18th Nov 2015
Dexamethasone reduced pain and swelling following third molar surgery
Dental Elf – 3rd Sep 2012
