Evaluation of methylprednisolone and flurbiprofen for inhibition of the postoperative inflammatory response

The ideal anti-inflammatory agent for use in third molar surgery should control pain, reduce swelling and trismus, and have no unwanted side effects. This investigation evaluated and compared the efficacy of corticosteroids, nonsteroidal anti-inflammatory agents, and placebo for reduction of the acute postoperative inflammatory response and its undesirable sequelae in patients undergoing the surgical removal of impacted third molars. Corticosteroids appeared to have maximal effect in controlling edema but had minimal analgesic effects. Nonsteroidal anti-inflammatory agents appear to be effective analgesics. A combination of these agents may be necessary to control the sequelae of oral surgical procedures most effectively.     

Antibiotic therapy in impacted third molar surgery

The use of routine antibiotic therapy in patients undergoing surgical third molar extraction is controversial. The efficacy of antibiotic therapy in preventing postoperative complications following surgical third molar extractions was evaluated in 141 patients. In the test group (66 patients), the protocol utilized a regimen of 2 g of amoxicillin orally daily for 5 d postoperatively, starting at the completion of surgery. In the control group (75 patients), no antibiotic therapy was given. No significant difference was found between the test group and the control group in the incidence of postoperative sequelae, i.e. fever, pain, swelling and alveolar osteitis. A statistically significant association between smoking, habitual drinking and increased postoperative pain and fever was found. Patient age > or = 18 yr was positively correlated with an increased incidence of alveolar osteitis. Swelling was found to be gender-related, in that female patients experienced more swelling than male patients. No correlation was found between the time required for surgery or difficulty of extraction and post-operative pain. In conclusion, no difference was found between patients receiving postoperative amoxicillin and the control group in the incidence of postoperative sequelae.     

Effects of preemptive analgesia with intravenous acetaminophen on postoperative pain relief in patients undergoing third molar surgery: a prospective,single-blind,randomized controlled trial

Background The efficacy of preemptive analgesia in managing postoperative pain remains controversial. The aim of this study was to compare the efficacy of intravenous (IV) acetaminophen administered before or immediately after the surgical extraction of an impacted mandibular third molar. Material and Methods This prospective randomized clinical trial included 120 patients. The patients were assigned to one of three groups: the preoperative-treatment group (pre-group), which received 1000 mg of IV acetaminophen 20 min before surgery; the postoperative-treatment group (post-group), which received 1000 mg of IV acetaminophen after surgery; the no-treatment group (control-group), which did not receive any analgesic. Rescue analgesic (60 mg loxoprofen) was issued to each patient, with instructions on self-administration if needed. For the rescue medication usage, the time of first loxoprofen usage and the total amount of loxoprofen consumption were obtained for a 17-hour period after surgery. We measured pain using the visual analogue scale at 1 hour and at 2, 3, 4, 5, and 15 hours after surgery. Results There was no significant difference in pain level among the three groups at any time interval. However, the pre-group demonstrated significantly lower rescue analgesic consumption and longer time until initial administration. Conclusions Administration of IV acetaminophen before third molar surgery provides more effective pain control than postoperative administration and no treatment. Key words:Preemptive analgesia, acetaminophen, impacted third molar, pain relief, randomized controlled trial.     

General technique of third molar removal

The most commonly performed surgical procedure in most oral and maxillofacial surgery practices is the removal of impacted third molars. Extensive training, skill, and experience allow this procedure to be performed in an atraumatic fashion with local anesthesia, sedation, or general anesthesia. The decision to remove symptomatic third molars is not usually difficult, but the decision to remove asymptomatic third molars is sometimes less clear and requires clinical experience. A wide body of literature (discussed elsewhere in this issue) attempts to establish clinical practice guidelines for dealing with impacted teeth. Data is beginning to accumulate from third molar studies, which hopefully will provide surgeons and their patients with evidence-based guidelines regarding elective third molar surgery.     

Comparison of the use of nalbuphine and fentanyl during third molar surgery

In a double-blind, randomized plan of drug administration, nalbuphine, fentanyl, and a placebo were compared for efficacy in sedation and analgesia during third molar removal. Fifty-eight patients participated in this study. Using accepted intravenous sedation and surgical techniques, fentanyl and nalbuphine were found to be better than placebo for anxiety and pain control in third molar surgery. Fentanyl had a longer duration of pain relief postoperatively than did nalbuphine. The study confirmed the need for a narcotic supplement to sedation techniques for third molar surgery.     

Comparative study of intravenous Tramadol versus Ketorolac for preventing postoperative pain after third molar surgery – A prospective randomized study

The aim of this comparative, prospective, randomized, controlled study was to evaluate two different regimens of analgesics: a preoperative intravenous dose of either Tramadol or Ketorolac given 10 min prior to surgery to assess their impact on clinical recovery after third molar surgery. Forty patients requiring surgical extraction of unilateral impacted mandibular third molars similar in position were enrolled in the study. Patients were randomly divided into two groups based on permuting the numbers. Patients in Group 1 and Group 2 were administered either Tramadol 50 mg or Ketorolac 30 mg, intravenously, 10 min prior to surgery. The difference in postoperative pain was assessed by four primary points: pain intensity as measured by a 10 mm visual analogue scale hourly for 12 h, median time to rescue analgesics, number of analgesics consumed and patient's overall 5-point global assessment scale. Throughout the 12 h investigation period, patients treated with Ketorolac reported significantly lower pain intensity scores, significantly longer time to rescue analgesics (Acetaminophen 500 mg) and less intake of postoperative analgesics. In Group 2, 40% of the patient had good overall assessment as compared to Group 1 where only 25% of patients had good overall assessment. The current study shows that pre-emptive use of Inj. Ketorolac 30 mg intravenously can reduce the severity of the postoperative sequelae of asymptomatic impacted mandibular third molar surgery.     

Postoperative swelling and trismus after mandibular third molar removal with the lingual split bone technique.

Several factors have been suggested as possible causes for the development of the swelling and trismus which occur after the surgical removal of impacted third molar teeth. In this investigation, measurements of swelling and trismus were made before and after lower third molar removal by the lingual split technique, in a series of 53 patients. No single cause of these surgical sequelae was identified and the duration and pattern of both swelling and trismus were recorded.     

Effect of exposed inferior alveolar neurovascular bundle during surgical removal of impacted lower third molars.

PURPOSE: In this prospective study, we sought to determine the incidence of inferior alveolar nerve (IAN) paresthesia in patients with an exposed IAN bundle seen intraoperatively. PATIENTS AND METHODS: We included consecutive patients undergoing third molar surgery in whom an exposed IAN bundle was seen in the third molar socket intraoperatively. Data recorded from patients included radiographic findings, variations in surgical method, intraoperative findings, complications, and postoperative sequelae. Patients were reviewed 1 week after surgery and evaluated subjectively and objectively to determine the incidence of paresthesia when the IAN bundle was exposed. Patients with paresthesia were followed for 2 years or until it resolved. RESULTS: An exposed IAN bundle was seen in 192 operation sites in 170 patients over a 5-year period, of which 166 patients with 187 operation sites were included in this study. Thirty-eight operation sites (20.3%) showed paresthesia at 1 week after surgery (95% confidence interval, 14.5% to 26.1%); 20 sites (15.0%) showed abnormal objective assessment results. By 3 months from surgery, 57.9% of nerves had recovered to normal sensation, 65.8% of nerves recovered by 6 months, and 71.1% of nerves recovered by 1 year. Eight patients were lost to follow-up. Logistic regression showed that the operator, male gender, older age, and root curvature were significant risk factors for paresthesia. CONCLUSIONS: Sighting an exposed intact IAN bundle during third molar surgery indicates its intimate relationship with the third molar and carries a 20% risk of paresthesia, with a 70% chance of recovery by 1 year from surgery.     

A review of dry socket: a double-blind study on the effectiveness of clindamycin in reducing the incidence of dry socket.

This double blind clinical study was undertaken to evaluate the effectiveness of locally applied clindamycin in Gelfoam in reducing the incidence of dry socket formation after third molar surgery. A total of 1,021 third molar extractions were performed, and 520 mandibular third molar extractions of varied surgical difficulty were evaluated. The results indicated that this technique was effective. This study also demonstrates that the incidence of dry socket after third molar surgery is significantly higher in the mandible than the maxilla, in smokers than in non-smokers, and in females currently on oral contraceptives.     

Indications for and anticipated difficulty of third molar surgery: a comparison between a dental hospital and a specialist high street practice

OBJECTIVE: To investigate the indications for and anticipated difficulty of third molar surgery between two different referral settings. DESIGN: A prospective study involving completion of a proforma pre- and post-operatively. SETTING: A dental teaching hospital and a specialist surgical dentistry practice in 2003. SUBJECTS AND METHODS: Patients referred for the assessment of their third molars were recruited. Details of the clinical and radiographical assessment for each patient were recorded pre-operatively and the extent of surgery required post-operatively. RESULTS: The main indication for referral for third molar extraction was pericoronitis in both centres. A larger number of patients were assessed and treated in a shorter period of time at the surgical dentist compared with the dental hospital. The surgical dentist was accurate in his assessment of the difficulty of surgery 96% of the time compared with 66% for the dental hospital staff. CONCLUSIONS: This study highlights the benefits for patients in being treated by a surgical dentist. As dental students require exposure to surgical dentistry in order to attain a level of competence, a reduction in the number of patients being referred to dental hospitals may impact upon students' ability to both assess and perform surgical procedures. This may mean that undergraduates will be less able to fulfil the recommendations of the General Dental Council. An outreach programme for final year dental students to surgical dentistry practices would benefit all concerned.     

A comparative study of the effect of two dosages of submucosal injection of dexamethasone on postoperative discomfort after third molar surgery: a prospective randomized study

Introduction

The aim of this clinical study was to evaluate and compare the relative efficacy of two different dosages of dexamethasone, i.e., 4 and 8 mg injected submucosally to reduce postoperative discomfort after mandibular third molar surgery.

Methodology

A prospective randomized study was conducted on 45 patients requiring surgical removal of an impacted third molar. Selected patients were divided randomly into three groups of 15 patients each: group I patients received one regimen single dose of 4 mg dexamethasone submucosally, group II received one regimen single dose of 8 mg dexamethasone submucosally, and group III (control group), no dexamethasone was given but only received injection of normal saline submucosally after establishing local anesthesia. The postoperative sequelae were assessed on the second and seventh postoperative day.

Result

As compared to group III, groups I and II showed statistically significant reduction in pain and swelling whereas no statistically significant difference was found between the test groups.

Conclusion

It can be concluded that corticosteroids are effective in curtailing the postoperative edema of lower third molar surgery but have negligible analgesic effect. As no statistically significant difference is found between both the regimes of dexamethasone, i.e., 4 and 8 mg so within the confines of our study, it may be concluded that 4 mg dexamethasone can be given safely to reduce the postoperative edema after the third molar surgery.

     

Do antibiotics reduce the frequency of surgical site infections after impacted mandibular third molar surgery?

Surgical removal of impacted third molars remains the most common procedure performed by oral and maxillofacial surgeons. Given the abundance of host bacteria within the operative sites, surgical site infections are among the most common complications of third molar removal, with an estimated frequency of 1% to 30%. In this setting, significant controversy has surrounded the use of prophylactic antibiotics in the surgical management of impacted third molars. This article provides a comprehensive review of the available data on antibiotic prophylaxis in impacted third molar surgery and offers specific recommendations on antibiotic use.     

Lingual flap retraction for third molar removal.

PURPOSE: Lingual nerve damage following lower third molar surgery remains a clinical problem. The traditional approach in the United States has been a buccal approach avoiding exposure or surgery on the lingual side of the crest of the ridge. An alternative technique is to deliberately expose the lingual tissues and retract the lingual nerve lingually before tooth removal. This study reports a trial of this technique. MATERIALS AND METHODS: Patients had removal of their lower third molars carried out using a technique that raises a lingual flap in addition to a buccal flap and places a specially designed lingual retractor to ensure that the lingual nerve is held out of the surgical field. This technique was used in cases where the crown of the tooth had to be sectioned or when distal bone needed to be removed. RESULTS: Two hundred fifty patients were treated by this method. There were 4 cases of transient lingual paresthesia, presumably caused by traction pressure from the retractor. Three of these cases were mild and resolved within 3 weeks. The fourth case had more profound paresthesia, but still resolved within 2 months. There were no cases of permanent nerve damage, and in many cases removal of the third molar was simplified by the superior access. CONCLUSION: Lingual retraction for third molar removal improves access to the surgical site and can simplify third molar removal. In this prospective study there were no cases of permanent lingual nerve injury.     

Influence of two different surgical techniques on the difficulty of impacted lower third molar extraction and their post-operative complications

Background

Post-operative complications of various degrees of severity are commonly observed in third molar impaction surgery. For this reason, a surgical procedure that decreases the trauma of bone and soft tissues should be a priority for surgeons. In the present study, we compare the efficacy and the post-operative complications of patients to whom two different surgical techniques were applied for impacted lower third molar extraction.

Material and Methods

Patients of the first group underwent the classical bur technique, while patients of the second group underwent another technique, in which an elevator was placed on the buccal surface of the impacted molar in order to luxate the alveolar socket more easily.

Results

Comparing the two techniques, we observed a statistically significant decrease in the duration of the procedure and in the need for tooth sectioning when applying the second surgical technique, while the post-operative complications were similar in the two groups. We also found a statistically significant lower incidence of lingual nerve lesions and only a slightly higher frequency of sharp mandibular bone irregularities in the second group, which however was not statistically significant.

Conclusions

The results of our study indicate that the surgical technique using an elevator on the buccal surface of the tooth seems to be a reliable method to extract impacted third molars safely, easily, quickly and with the minimum trauma to the surrounding tissues. Key words:Mandibular third molar, impacted, surgical technique, extraction, elevator.     

Risk factors associated with prolonged recovery and delayed healing after third molar surgery

PURPOSE: We sought to identify the demographic, oral health, and surgical risk factors associated with prolonged recovery after third molar surgery using health-related quality of life (HRQOL) and clinical outcomes. PATIENTS AND METHODS: HRQOL responses from patients and clinical outcomes were obtained after third molar surgery. Criteria were selected for HRQOL outcomes that separated patients with from those without prolonged recovery. Delayed clinical healing was indicated by a patient having at least 1 postsurgery visit with treatment. Risk assessment models for prolonged HRQOL recovery and delayed clinical healing were developed using stepwise logistic regression analysis. RESULTS: We included 547 subjects with HRQOL and clinical outcome data in this analysis. Age, gender, and occlusal plane position were statistically significantly associated with prolonged recovery for early symptoms, oral function, and pain. Recovery for lifestyle was prolonged only if both lower third molars were below the occlusal plane before surgery. Age, gender, prior symptoms related to the third molars, and the surgeon's perception of difficulty were statistically significant predictors of delayed clinical recovery. CONCLUSIONS: Certain demographic and oral health conditions available to the surgeon before surgery, and characteristics of the surgery itself, increase the risk of a prolonged recovery for HRQOL outcomes and delayed clinical outcomes after third molar surgery.     

Do antibacterial mouthrinses affect bacteraemia in third molar surgery? A pilot study

Background: The aim of this pilot study was to evaluate the effects of mouthrinses containing 7.5% povidone iodine and 0.2% chlorhexidine on bacteraemia following impacted third molar surgery. Methods: Thirty‐four patients were enrolled in this study. Patients in the first group were asked to rinse their mouth with the mouthrinse containing 7.5% povidone iodine, patients in the second group were asked to rinse with the mouthrinse containing 0.2% chlorhexidine and patients in the third group were asked to rinse with 0.9% NaCl (sterile saline) solution. All rinses were used for one minute preoperatively. Peripheral venous blood samples were collected at baseline (preoperatively), 1 and 15 minutes after the completion of surgical tooth removal. Each blood sample was divided in two, placed in aerobic and anaerobic culture bottles and processed for microbiological examination. Results: Bactaeremia was detected in 33% of the povidone iodine group, 33% of the chlorhexidine group and 50% of the control group. Isolated bacteria were 58% anaerobes and predominantly 92%Streptococcus species. Incidence of bacteraemia was reduced with chlorhexidine and povidone iodine mouthrinses in third molar surgery, although the difference was not statistically significant (p > 0.05). Conclusions: Bacteraemia was reduced with antibacterial mouthrinses in third molar surgery. The results of this study should be confirmed with further studies conducted on a larger patient population and with different antibacterial mouthrinses.     

Evaluation of intra-alveolar chlorhexidine dressings after removal of impacted mandibular third molars.

Chlorhexidine gluconate (CHX) has been investigated for its possible benefit in the prevention of alveolar osteitis complicating third molar removal. In a double-blind, placebo-controlled clinical study, 70 randomly selected healthy patients were subjected to uncomplicated mandibular third molar removal followed by CHX-gelatin sponge and saline solution-gelatin sponge intra-alveolar dressings. Each patient was followed for 6 days for postoperative discomfort and complications, and scored accordingly. The results demonstrated that patients receiving 0.2% CHX intra-alveolar dressings exhibited a significant reduction in postoperative discomfort and complications when compared with saline solution-treated control sites (p less than 0.005). Further, this phenomenon was not found to be related to patient factors including age, sex, and race, nor did any correlation exist between treated or control sites, and surgical factors including performing surgeon, surgeon's dominant hand, time of surgery, surgical site, and difficulty of the removal. These findings warrant further studies concerning the apparent clinical benefit of postextraction intra-alveolar CHX dressings for the reduction of postoperative alveolar osteitis.     

The impact of intravenous antibiotics on health-related quality of life outcomes and clinical recovery after third molar surgery.

PURPOSE: We sought to compare recovery for clinical and health-related quality of life (HRQOL) outcomes after third molar surgery in patients treated with or without intravenous antibiotics at surgery. PATIENTS AND METHODS: Fifty-six patients at least 18 years of age and with all 4 third molars below the occlusal plane, treated at 3 clinical centers, were given intravenous antibiotics just before third molar surgery. Clinical and HRQOL outcomes of these patients were compared with those of a nonconcurrent control group (n = 60 patients) who did not receive antibiotics. The control group was selected using the same criteria and treated under the same surgical protocol as the antibiotic group. Differences between the groups were assessed with Cochran-Mantel-Haenszel row mean score statistics. RESULTS: The incidence of delayed clinical recovery defined as a postsurgery visit with treatment was higher in the control group compared with the antibiotic group. In the antibiotic group, 4% had 1 postsurgery visit with treatment; no patient had 2 visits. In the control group without antibiotics, 28% had at least 1 postsurgery visit with treatment (P <.0001) and 13% had at least 2 postsurgery visits with treatment. No statistically significant differences in HRQOL outcomes were found between the 2 groups. CONCLUSIONS: Administration of intravenous antibiotics before third molar surgery may improve clinical recovery in healthy adult patients with all 4 third molars below the occlusal plane, a presenting characteristic that has been suggested as a risk factor for delayed recovery. The findings from this exploratory trial indicate that evaluation of the effectiveness of systemic antibiotic administration with third molar surgery in a randomized, multi-intervention, explanatory clinical trial is warranted.     

A comparitive study of diclofenac transdermal patch against oral diclofenac for pain control following removal of mandibular impacted third molars

Objective  The objectives of this study was to evaluate subjectively the analgesic efficacy of Oral Diclofenac Sodium against Diclofenac Sodium Transdermal patch in the management of postoperative pain following surgical removal of impacted mandibular third molars. Materials and methods  Twenty healthy subjects belonging to both the sexes in the age group of 18–40 years with bilateral mesioangular impactions of mandibular third molar teeth underwent surgical removal under local anaesthesia by administering an inferior alveolar nerve block on two different occasions with a minimum interval of 1 week in-between the procedures. The postoperative pain was recorded on visual analog scale, a verbal rating scale, a pain relief scale and a pain intensity scale. Readings were taken at 2 hours, 4 hours, 8 hours, 12 hours and 24 hours postoperatively, taking the time at which the surgery was completed as a reference. On the second and third days, the repeat medication was administered at that reference time and recordings taken at the same intervals for a total of 3 days. Patients received the study medication i.e. Diclofenac Sodium 100mg once a day for 3 days after performing surgery on one side and the same patients were given Diclofenac Sodium Transdermal Patch 100mg once a day for 3 days after performing surgery on the contralateral side. Results and observations  Both the statistical analysis and clinical observation showed that on the first postoperative day diclofenac sodium administered orally has slightly more significant efficacy when compared to the drug administered transdermally. However, on the second and third postoperative days there was no statistical or clinical difference in the pain control by either route of administration. Conclusions  The study concludes that transdermal diclofenac sodium can be used as an alternative form of pain control following removal of impacted mandibular third molars, however considering that the analgesic potency might be lesser in the immediate postoperative period, it might be prudent to use oral diclofenac sodium for immediate postoperative pain relief, following which transdermal route can be used for pain control.