thesis discussion.docx

7/28/2019 thesis discussion.docx

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Discussion

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Surgical removal of impacted mandibular third molars is the most

frequent surgical intervention in oral surgery. The most common reasons for

removal of impacted third molars include recurrent pericoronitis, periodontal

problems, un-restorable carious lesions on second or third mandibular molars,

presence of cysts or tumors or to prevent future complications.(6)

The surgical extraction of impacted mandibular third molars

often causes swelling of facial soft tissues, trismus and pain. (9 ) These are

attributed to the inflammation produced as a result of surgical trauma. Oral

surgeons have been using corticosteroids to minimize these sequelae and have

obtained satisfactory results. (15)

In 1949, Hench and Kendal used corticosteroids as anti

inflammatory agents for the treatment of rheumatoid arthritis. Their use in

dental practice began in the early 1950s when Spies etal, Strean and Horton

administered hydrocortisone to prevent inflammation in oral surgery. (23).

Different corticosteroids with different efficacies, biological half lives and

mineralocorticoid activities have been used since then (10).

Steroids are known to exert their anti inflammatory activity by

preventing the release of fatty acids from membrane phospholipids, thereby

reducing formation of cyclooxygenase and lipooxygenase product which are

important inducers of post operative inflammatory process leading to edema

and pain.(1). The analgesic activity of glucocorticoids has been related to their


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Discussion

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anti-inflammatory action by inhibiting phospholipase A2 and thus inhibiting

the formation of arachidonic acid (1). In order to reduce inflammation,

corticosteroids must be administered at doses in excess of the physiological

concentrations released under normal conditions. (4).

Ideal glucocorticoids should possess only minimum

mineralocorticoid action and provide therapeutic activity on the immediate

postoperative period that is when the inflammatory reaction is most intense.

(steroids in m3). Various synthetic formulations of steroids which undergo

slower metabolism leading to prolonged plasma and tissue levels of the drugs

are now being available(10).

Dexamethasone and methylprednisolone are the most widely

used corticosteroids in oral surgery primarily due to great anti-inflammatory

actions and minimal mineralocorticoid effect. A pervasive argument for use of

dexamethasone is prevention of a rebound swelling on second and third

postoperative days. However Stephen etal (28) did not observe any rebound

swelling in their study. Tarek etal(5) reported less pain and trismus with

submucosal infiltration of 125mg methylprednisolone when compared to 4mg

of submucosal dexamethasone infiltration.

We have chosen methylprednisolone because it is fivefold more

potent than hydrocortisone, has less mineralocorticoid action and a biological

half life of 18-36 hours.(12).

Methylprednisolone has been widely used in oral surgical

procedures for its anti inflammatory actions in doses of 10mg, 40mg, 80mg

and 125mg. Huffman etal( j.oral surg 1977) did not observe any statistically


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Discussion

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significant clinical differences between the administration of 40mg or 125mg

intravenous methylprednisolone. Ustun etal (3) compared the efficacy of two

intravenous doses of methylprednisolone. No significant benefit of 3mg/kg

MP in comparison with1.5mg/kg was detected. Schultz-Mosgau etal (use of

ibu ndmp) noted a decrease in selling of 56% and in pain perception of 67%

after a perioperative application of 64mg methylprednisolone orally. J.M Mico

etal (4) with 40mg intramuscular injection of methylprednisolone into the

gluteal muscle, C.S.Holland (11) with 40mg preoperative intravenous

methylprednisolone and Emin Essen etal (2) with 125mg intravenous

preoperative administration of methylprednisolone reported a significant

reduction of swelling, pain and trismus when compared to placebo. Milles etal

(9) reported a significant reduction in swelling during first three days after

mandibular third molar surgery using 16mg methylprednisolone orally, the

evening before surgery and 20mg IV immediately prior to surgery.

Various routes of administration (PO,IV,IM and Submucosal)

of administration of steroids have been advocated. Graziani etal(15) reported

that endoalveolar application of 4mg dexamethasone powder at the operation

site offered an effective reduction of post operative sequelae. E.Vegasetal (23),

Jasmine Kaur etal(29), and Loganathan etal(25) evaluated intra massetric

injection of 40mg methylprednisolone and found that there was a significant

action against inflammation.

The intramuscular route of steroid application has also been

shown to decrease sequelae in the immediate post interventional period (22).

But there are several stringent reasons to avoid the intra muscular application

of steroids. A slow onset of action highly dependent on the rate of blood flow


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Discussion

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at the site of administration,an increased risk of adrenal suppression (3) andlocal complications like necrosis, hematoma and abscess formation are the

adverse reactions of intramuscular injection(28).

Carmen etal (8) observed a reduction of inflammation with

4mg oral methylprednisolone when compared to its local injection. Ibrahim.S

etal (1) found reduction of swelling and pain with oral administration of 10mg

MP when compared to its local injection. Though oral dosing is possibly the

most comfortable option for the patient, it does not seem to be as effective as

parenteral administration. (effect of mp on m3)

Due to the attainment of the instant plasma drug concentration,

the intravenous application is frequently considered to be most effective route

of administration. (2). Sayed etal investigated the pharmacokinetics of

intravenous methylprednisolone sodium succinate and oral

methylprednisolone and reported that the bioavailability of drug is incomplete

following oral administration.(18). Emin etal (2) observed a significant

decrease of edema, trismus and facial pain in patients receiving pre

interventional administration of 125mg MP intravenously. Studies have shown

that parenteral administration of the steroid pre operatively and immediately

after surgery obtained good results. (10). So in our study we administered

intravenous methylprednisolone both preoperatively and after 6 hours

postoperatively to ensure adequate concentration of the plasma levels of the

drug during the post operative period.

A few investigators have put forward that MP in combination NSAIDS

would offer improved relief of symptoms. M.Cemil etal(22) reported a greater


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Discussion

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relief of pain of symptoms with a combination of 25mg intra muscular

prednisolone and diclofenc potassium. O.A.Olstad (12) suggested that MP in

combination with paracetamol may hasten the onset of analgesia.

Methylprednisolone offered superior anti-inflammatory actions but its

combination with flurbiprofen or ibuprofen provide greater initial

analgesia(14,15). Edin Selvimovic etal (30) reported an enhanced impact on

reduction of post operative pain and swelling by combined therapy of MP and

meloxicam. Marc Leon etal (7) reported only a transient improvement of

analgesia by using a combination of paracetamol and MP when compared to

ketoprofen. In our study, 50mg diclofenac sodium was given in common to all

patients in both steroid and placebo groups.

Various methods have been used to measure facial swelling

/edema. In our study, facial swelling was determined by a modification of tape

measuring method of Gabka and Matsumara (16). Obviously, this method is

not as accurate as computed tomography(CT) or magnetic resonance imaging

(MRI) for making precise measurement of facial soft tissue volume. However,

it is a non invasive, simple, cost effective and time saving method which

provides numeric data for determination of tissue contour changes. Milles etal

(9) reported that swelling may increase on the third day after surgery. So we

recalled the patient on the second post operative day to record the intensity of

swelling pain and trismus In our study, the steroid group showed a significant

(p< 0.05) reduction of swelling when compared to placebo on 2nd post

operative day while the difference was insignificant (p > 0.05) on 7th post

operative day. By the 7th post operative day the facial measurements have

returned to the pre operative measurements in both the groups suggesting that


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Discussion

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post operative dose of the steroid was effective in limiting the rebound

swelling that would occur within the first 48-72 hours.

Trismus was maximum in both the groups on second post

operative day but the steroid group showed a significantly (< 0.05) greater

amount of mouth opening when compared to placebo group. From

preoperative day to 2nd post operative day, pain scores were significantly

higher in placebo when compare to steroid group. However all the parameters

returned to the preoperative scores by 7th post operative day in both the

groups.

The steroid group did not show any significant reduction in

WBC count post operatively, indicating that short term steroid dose as

administered in our study would not result in steroid induced leucopoenia

Thus our study concluded that pre and post operative

administration of intravenous methylprednisolone obtained only a transient

(5%) reduction of post operative complications after mandibular third molar

surgery when compared to the placebo suggesting the necessity for further

studies with different dosage schedules to arrive at significant conclusions.

.

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thesis discussion.docx