Introduction

The prophylactic or therapeutic, mandibular third molar surgery, is one of the most commonly performed minor surgical procedure in dental surgery (Kumar, Abbas, Fasuto, & Aster, 2010; McGrath, Comfort, Lo, & Luo, 2003). This procedure inevitably results in trauma to hard and soft tissues; consequently, frequent postoperative complications of mandibular third molar impaction such as significant swelling, pain, and reduced inter incisal distance may be experienced by patients which diminishes their quality of life (Bamgbose et al., 2005; Worrall, Riden, Haskell, & Corrigan, 1998). Patients quality of life after oral surgical procedures has been discussed in various medical and social science literature over the past few decades (Grossi et al., 2007). The quality of life has and is usually considered as a patient's impression of his situation in life, which is the impact of the disease and treatment (Buyukkurt, Gungormus, & Kaya, 2006; McGrath, Comfort, Lo, & Luo, 2003). Maxillofacial surgeons, should be committed enough to render better control of this postoperative sequelae and discomfort for patients undergoing third molar impaction procedure (Ogden, Bissias, Ruta, & Ogston, 1998).

Different techniques have been proposed in the literature to control the postoperative swelling, of which corticosteroids have been broadly utilised in an oral and maxillofacial medical procedure to control inflammation and the associated symptoms of third molar impaction procedure for several decades (Doward & McKenna, 2004; Kaplan, 2003). The anti-inflammatory action of corticosteroids has been used to lessen oedema instigated by the surgery; however, their immediate effects on the control of pain and trismus are still controversial (Esen, Taşar, & Akhan, 1999).

Corticosteroids are a group of drugs which have identical chemical formula as steroidal hormones which are secreted by the adrenal gland. These hormonal steroids based on their biological effects are classified as glucocorticoids and mineralocorticoids (Zandi, 2012). A large number of steroids are released into the circulation by the adrenal gland, and two are of greater importance are aldosterone, which is a mineralocorticoid, and cortisol, which is a glucocorticoid. Dexamethasone (administered either orally, submucosally, IV or IM), methylprednisolone acetate and methylprednisolone sodium succinate (IV or IM or submucosal) are most commonly preferred corticosteroids in oral and maxillofacial surgery. These corticosteroids decrease the postoperative sequelae of mandibular third molar impaction procedure in many patients and therefore, decrease the morbidity and improve the personal satisfaction of the patient by reducing the discomfort following the procedure (Aditya & Sanghavi, 2015; Fonseca, Marciani, & Turvey, 2009). To our knowledge this is the first article to systematically review the comparison of the effectiveness of submucosal administration of dexamethasone with methylprednisolone following mandibular third molar impaction in reducing the postoperative sequelae and its discomfort.

Materials and Methods

Structured question

Is submucosal administration of dexamethasone better at controlling postoperative sequelae compared to submucosal administration of methylprednisolone in patients undergoing mandibular third molar impaction procedure?

PICO analysis

Population: Patients undergoing mandibular third molar impaction procedure

Intervention: Submucosal dexamethasone

Comparison: Submucosal methylprednisolone

Outcome: Postoperative control of pain, swelling and trismus are the variables of interest as shown in Table 1.

Source and Search strategy

The online databases, including Medline, PubMed central and advanced indexes, were last searched until December 2019. Clinical studies and review bibliographies are identified in the online search and were analysed. Also, a hand search of various journals was done. A search strategy was based on English language journals only. Reference list of the reviews and the identified studies were also checked for possible additional studies.

Selection Criteria

This systematic review sought to assess the randomised clinical studies comparing the effect of the dexamethasone versus methylprednisolone through submucosal administration after mandibular third molar impaction procedure performed in humans.

Inclusion Criteria

All randomised controlled trials of patients of age higher than 16 years having lower third molars indicated for impaction, based on the structured research question were involved in this review.

Exclusion Criteria

Case reports, case series, animal studies, in vitro studies, retrospective studies, review articles, articles from other languages and studies comparing different routes of administration of corticosteroid drug were excluded.

Types of Outcome Measure

Control of postoperative pain, oedema and trismus

All the articles included in this systematic review were subjected to methodological quality assessment and risk of bias was evaluated.

Results

Forty-eight articles were obtained from the electronic search utilising the keywords, and two articles were yielded from hand search.

Finally, two articles satisfied the inclusion criteria and were analysed in this systematic review, as seen in Figure 1. One study was obtained by electronic literature search, and one article from hand search was included. Two independent examiners evaluated these two articles according to the inclusion criteria. General information and characteristics of selected articles were tabulated in Table 2, Table 3 and Table 4.

Sample size, level of evidence of article, type of impaction done, mean age group, gender, a dosage of drugs were analysed. Mean age group included in both the clinical trial was around 25-50 years, and mandibular third molar impaction procedure was performed in both the articles.

Both the included article has a placebo group, dexamethasone group and methylprednisolone group. Corticosteroid drug was administered submucosally preoperatively, one article has analysed the results using 4mg dexamethasone, and other article had 8mg dexamethasone compared with 40 mg methylprednisolone in both reports.

Mean duration of the impaction procedure was around 20-35 min approximately. Methodology and assessment of the outcome results are tabulated in Table 5, Table 6 and Table 7, respectively. Also, both the articles experience a moderate risk of bias, as seen in table Table 8 and Table 9.

Discussion

Around the age range of 18–30 years, where an individual undergoes both personal and professional growth, third molars usually erupt. Out of various corticosteroids, dexamethasone and methylprednisolone are the most common ones used in oral surgery and literature are filled with multiple studies on comparing these two drugs (GP, 1989; Glick, 1989). Also submucosal route of administration has become one of the easiest and safest ways of administration of a drug (Beirne & Hollander, 1986; Tiwana et al., 2005). A series of postoperative sequelae associated with functional and structural alterations are usually seen following third molar impaction procedure which in turn affects the quality of life of patients for the initial few days after surgery (Messer & Keller, 1975; Moore, Brar, Smiga, & Costello, 2005). Pain also lies upon a few different factors, for example, injury to tissues during surgery, individual's torment edge and mental prosperity (Seymour, Meechan, Yates, Seymour, & Walton, 1999; Tripathi, 2013). Inflammation and trismus go hand in hand as it is considered that one of the many factors leading to reduced interincisal distance after a third molar impaction procedure is inflammation but decreased mouth opening may also result in pain from the masticatory muscle exhibiting its inhibitory effect, due to its proximity to the surgical site (Valeriani et al., 1999). Several different components that may worsen the postoperative discomfort includes lengthened time taken for surgery, traumatic extraction and accidental local anaesthetic injection into the masticatory muscle. These acts as a confounding factor of the clinical studies reviewed here (Romaniello, Cruccu, McMillan, Arendt-Nielsen, & Svensson, 2000). Submucosal administration of dexamethasone is most efficient when given systemically as it contributes to an increased drug concentration at the site of surgery. It represents a straightforward, simple to use and practical treatment option in contrast to other treatment modalities (Chugh et al., 2018; Lim et al., 2017).

Corticosteroid administration has been related in various studies for a reduction in postoperative third molar impaction procedure complications. However, deviation in the drug dosing and route of administration of corticosteroid drugs persists (Hafez, Elsharrawy, & Abdelmabood, 2014). Thus, dexamethasone and methylprednisolone have proved to be a successful alternative for lessening postoperative discomfort after third molar impaction procedure to a certain degree, independent of the course, and the timing of drug administration. Up until now, there have been two studies embraced to analyse the viability of dexamethasone versus methylprednisolone administered submucosally in reducing the postoperative sequelae of third molar impaction procedure.

Implications for evidence-based practice from this systematic review is that dexamethasone is more efficient in controlling oedema and trismus as compared to methylprednisolone. But both drugs have similar pain controlling ability. But the age of the patient, morphology of the tooth and amount of bone covering the tooth as well as surgeon skill should also be taken into consideration. Further studies are needed to be undertaken, which include all parameters mentioned above to establish this fact.

Conclusion

Submucosal injection of dexamethasone diminishes the signs and manifestations markedly resulting from third molar impaction procedure. It appears that the potential analgesic effect of corticosteroids, if proved with proper randomised controlled trials with higher sample size, possess a guarantee to enhance their future compliance of the drug into a routine dental practice, despite the fact of remaining controversial and debatable.

Acknowledgement

The authors are grateful to the professor and Head of the department of oral and maxillofacial surgery for his guidance in this research work.

Funding Support

No source of funding.

Conflict of Interest

None of the authors declare any conflicts of interest.