J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 11, Number 7, July 2019, pages 501-508

Dexamethasone Injection Into Pterygomandibular Space Versus Sublingual Space on Post-Operative Sequalae of Lower Third Molar Intervention

Figure 2. Three reference lines for facial length measurement. A: lateral corner of eye to angle of mandible; B: corner of mouth to border of earlobe; C: soft tissue pogonion to border of earlobe.

**Table 1.** Eligibility Criteria Selection of the Patients
Inclusion criteria selection of the patients
The patient has bilateral impacted lower third molars symmetrically positioned on both sides of the mandible of which surgical removal consists of flap operation, bone removal, and tooth section
Aged between 18 - 45 years
No history of allergy to dexamethasone, amoxicillin, or acetaminophen
No use of other medicine 1 month before and during the study period
The patient is able to understand and carry out the instructions given by the investigators
The patient has provided their consent for the study
Pregnancy or current lactation
Patients with cardiovascular problems, renal and/or liver failure, or other serious medical conditions
Allergic to local anesthetics and other drugs that were used in this study
Patient with facial deformities that may interfere with the injections, surgery or evaluation
The existence of acute infection and/or swelling and pain at the time of surgery
Patients taking any medication during the previous 1 month prior to the surgery
Inability to follow the instructions or cooperate during the study
Duration of treatment more than 1 h

Table 1. Eligibility Criteria Selection of the Patients

Inclusion criteria selection of the patients

The patient has bilateral impacted lower third molars symmetrically positioned on both sides of the mandible of which surgical removal consists of flap operation, bone removal, and tooth section

Aged between 18 - 45 years

No history of allergy to dexamethasone, amoxicillin, or acetaminophen

No use of other medicine 1 month before and during the study period

The patient is able to understand and carry out the instructions given by the investigators

The patient has provided their consent for the study

Exclusion criteria selection of the patients

Pregnancy or current lactation

Patients with cardiovascular problems, renal and/or liver failure, or other serious medical conditions

Allergic to local anesthetics and other drugs that were used in this study

Patient with facial deformities that may interfere with the injections, surgery or evaluation

The existence of acute infection and/or swelling and pain at the time of surgery

Patients taking any medication during the previous 1 month prior to the surgery

Inability to follow the instructions or cooperate during the study

Duration of treatment more than 1 h

**Table 2.** Demographic Data of Patients in Study Groups
Data consideration	8 mg dexamethasone	Total	Percentage
Position A: the part of the lower third molar is above the occlusal plane of the lower second molar; Position B: the highest portion of the lower third molar is between the occlusal plane and the cervical line of the second molar; Class I: there is sufficient space of accommodation of the mesio-distal diameter of the lower third molar; Class II: the space of accommodation of the mesio-distal diameter of the lower third molar is less than the mesio-distal diameter of the lower third molar.
Number	30	30	60	100
Age
16 - 25 years	28	28	56	93.3
26 - 32 years	2	2	4	6.6
Sex
Male	13	13	26	43.3
Female	17	17	34	56.7
Position
A	9	9	18	30
B	21	21	42	70
Class
I	12	12	24	40
II	18	18	36	60

Table 2. Demographic Data of Patients in Study Groups

Data consideration

8 mg dexamethasone

Total

Percentage

Pterygomandibular space injection

Sublingual space injection

Position A: the part of the lower third molar is above the occlusal plane of the lower second molar; Position B: the highest portion of the lower third molar is between the occlusal plane and the cervical line of the second molar; Class I: there is sufficient space of accommodation of the mesio-distal diameter of the lower third molar; Class II: the space of accommodation of the mesio-distal diameter of the lower third molar is less than the mesio-distal diameter of the lower third molar.

Number

100

Age

16 - 25 years

93.3

26 - 32 years

6.6

Sex

Male

43.3

Female

56.7

Position

Class

**Table 3.** Duration of Mandibular Third Molar Intervention of the Patients in Study Groups
Data consideration	8 mg dexamethasone	P value
Duration of operation (min)	19.93 (2.71)	20.50 (2.77)	0.225

Table 3. Duration of Mandibular Third Molar Intervention of the Patients in Study Groups

Data consideration

8 mg dexamethasone

P value

Pterygomandibular space injection (SD)

Sublingual space injection (SD)

Duration of operation (min)

19.93 (2.71)

20.50 (2.77)

0.225

**Table 4.** Measurements of Post-Operative Pain (VAS in Millimeters and Number of Analgesic Taken in Number of Tablets) in Study Groups
Data evaluation	8 mg dexamethasone	P value
Day 0: immediate after operation; Day 1: first day after operation; Day 2: second day after operation; Day 3: third day after operation; Day 7: seventh day after operation.
VAS
Day 0	21.57 (15.76)	20.90 (15.14)	0.840
Day 1	18.90 (14.96)	17.03 (14.23)	0.532
Day 2	14.17 (15.45)	13.90 (13.87)	0.935
Day 7	3.67 (10.15)	3.60 (8.25)	0.971
Number of analgesic taken
Day 1	1.87 (1.04)	1.77 (0.97)	0.682
Day 2	2.67 (1.82)	2.53 (1.59)	0.742
Day 3	1.47 (1.47)	1.10 (1.29)	0.304

Table 4. Measurements of Post-Operative Pain (VAS in Millimeters and Number of Analgesic Taken in Number of Tablets) in Study Groups

Data evaluation

8 mg dexamethasone

P value

Pterygomandibular space injection (SD)

Sublingual space injection (SD)

Day 0: immediate after operation; Day 1: first day after operation; Day 2: second day after operation; Day 3: third day after operation; Day 7: seventh day after operation.

VAS

Day 0

21.57 (15.76)

20.90 (15.14)

0.840

Day 1

18.90 (14.96)

17.03 (14.23)

0.532

Day 2

14.17 (15.45)

13.90 (13.87)

0.935

Day 7

3.67 (10.15)

3.60 (8.25)

0.971

Number of analgesic taken

Day 1

1.87 (1.04)

1.77 (0.97)

0.682

Day 2

2.67 (1.82)

2.53 (1.59)

0.742

Day 3

1.47 (1.47)

1.10 (1.29)

0.304

**Table 5.** Swelling Measurements and Differences in Millimeters From Baseline Value in Study Groups
Data evaluation	8 mg dexamethasone	P value
Tr-Com: tragus-commissure of mouth; Tr-Pog: tragus-pogonion; Gn-Lc: goial angle-lateral canthal of eye.
Tr-Com
Baseline	115.10 (6.05)	115.03 (6.12)	0.326
Second day	118.83 (6.84)	118.66 (6.01)	0.724
Seventh day	116.56 (6.85)	116.53 (6.22)	0.926
Differences
Second day-baseline	3.73 (2.42)	3.63 (2.44)	0.835
Seventh day-baseline	1.46 (2.14)	1.50 (1.50)	0.926
Tr-Pog
Baseline	115.10 (6.05)	115.03 (6.12)	0.326
Second day	118.83 (6.84)	118.66 (6.01)	0.724
Seventh day	116.56 (6.85)	116.53 (6.22)	0.926
Differences
Second day-baseline	3.73 (2.42)	3.63 (2.44)	0.835
Seventh day-baseline	1.46 (2.14)	1.50 (1.50)	0.926
Gn-Lc
Baseline	106.86 (8.52)	105.6 (7.92)	0.99
Second day	110.83 (8.02)	109.53 (7.65)	0.177
Seventh day	108.56 (8.16)	107.26 (7.77)	0.115
Differences
Second day-baseline	3.96 (2.57)	3.93 (2.11)	0.954
Seventh day-baseline	1.7 (2.56)	1.6 (2.13)	0.897

Table 5. Swelling Measurements and Differences in Millimeters From Baseline Value in Study Groups

Data evaluation

8 mg dexamethasone

P value

Pterygomandibular space injection, mean (SD)

Sublingual space injection, mean (SD)

Tr-Com: tragus-commissure of mouth; Tr-Pog: tragus-pogonion; Gn-Lc: goial angle-lateral canthal of eye.

Tr-Com

Baseline

115.10 (6.05)

115.03 (6.12)

0.326

Second day

118.83 (6.84)

118.66 (6.01)

0.724

Seventh day

116.56 (6.85)

116.53 (6.22)

0.926

Differences

Second day-baseline

3.73 (2.42)

3.63 (2.44)

0.835

Seventh day-baseline

1.46 (2.14)

1.50 (1.50)

0.926

Tr-Pog

Baseline

115.10 (6.05)

115.03 (6.12)

0.326

Second day

118.83 (6.84)

118.66 (6.01)

0.724

Seventh day

116.56 (6.85)

116.53 (6.22)

0.926

Differences

Second day-baseline

3.73 (2.42)

3.63 (2.44)

0.835

Seventh day-baseline

1.46 (2.14)

1.50 (1.50)

0.926

Gn-Lc

Baseline

106.86 (8.52)

105.6 (7.92)

0.99

Second day

110.83 (8.02)

109.53 (7.65)

0.177

Seventh day

108.56 (8.16)

107.26 (7.77)

0.115

Differences

Second day-baseline

3.96 (2.57)

3.93 (2.11)

0.954

Seventh day-baseline

1.7 (2.56)

1.6 (2.13)

0.897

**Table 6.** Measurements of Limited Mouth Opening and Differences in Millimeters From Baseline Value in the Study Groups
Maximum incisal distance	8 mg dexamethasone	P value
*P < 0.01.
Baseline	46.36 (5.03)	46.36 (5.03)	1
Second day	33.83 (7.68)	36.96 (5.49)	0.004*
Seventh day	42.61 (5.11)	43.23 (4.88)	0.293
Differences
Baseline-second day	12.53 (6.62)	9.40 (5.11)	0.004*
Baseline-seventh day	3.75 (3.74)	3.13 (2.62)	0.293

Table 6. Measurements of Limited Mouth Opening and Differences in Millimeters From Baseline Value in the Study Groups

Maximum incisal distance

8 mg dexamethasone

P value

Pterygomandibular space injection (SD)

Sublingual space injection (SD)

*P < 0.01.

Baseline

46.36 (5.03)

Second day

33.83 (7.68)

36.96 (5.49)

0.004*

Seventh day

42.61 (5.11)

43.23 (4.88)

0.293

Differences

Baseline-second day

12.53 (6.62)

9.40 (5.11)

0.004*

Baseline-seventh day

3.75 (3.74)

3.13 (2.62)

0.293

**Table 7.** The Summary of Previous Studies of Dexamethasone
Authors	Year	Type of steroid	Administration	Parameter measurement	Results
NA: unknown; HRQOL: health-related quality of life; IV: intravenous.
Baxendale et al [15]	1993	8 mg dexamethasone	Oral	Post-operative pain: 4 h post-operative reduction	Significant reduction in pain 4 h post-operatively
Tiwana et al [12]	2005	NA corticosteroids and without antibiotics, no corticosteroids	Intravenous before surgery	Effect on health-related quality of life outcomes	IV corticosteroid administration had a limited, but beneficial effect on HRQOL outcomes
Grossi et al [6]	2007	4 and 8 mg dexamethasone	Submucosal injection before surgery	Post-operative edema	Significant reduction when 4 mg dexamethasone was given, but 8 mg provided no further benefit
Filho et al [2]	2008	4 and 8 mg dexamethasone	The consumption of 4 mg versus 8 mg before surgery	Swelling, trismus, pain	Better for swelling and trismus but not effective for pain
Mojsa et al [8]	2011	4 mg dexamethasone	4 mg injection, the “before” group, placebo group, the “after” group	Facial swelling, post-operative pain, trismus	Better control of pain, swelling, trismus
Antonio et al [9]	2011	8 mg dexamethasone	The oral administration, local injection in the masseter muscle	Pain, edema, limited mouth opening	Reducing post-operative pain, edema, trismus
Tiigimae-Saar et al [11]	2011	Single dose of 30 mg prednisolone, 120 mg etorikoxib	Prednisolone immediate before operation, etorikoxib 30 min before operation	Pain, facial swelling, trismus	Well-suited for treatment of post-operative pain, trismus, swelling, diminishing post-operative swelling of soft tissues
Chaurand-Lara and Facio-Umana [10]	2013	20 mg of methylprednisolone	Intramuscular in masseter and no administer	Swelling, pain	Decrease and an effective therapeutic reduction of swelling and pain
Bauer et al [14]	2013	NA ibuprofen or placebo, NA ibuprofen + dexamethasone, placebo	Pre-emptive analgesia	Post-operative pain	Pre-emptive analgesia insufficient to inhibit central sensitization, association with dexamethasone more effective
Li et al [16]	2013	4 mg and 8 mg dexamethasone	Injection of 4 - 5 mg in pericoronal injection	Post-operative swelling, trismus	Control facial swelling, trismus
Latt et al [17]	2016	Dexamethasone 8 mg, saline group	Pterygomandibular space injection	Post-operative pain	Decreased post-operative pain
Gozali et al [18]	2017	8 mg dexamethasone, saline group	Injection into sublingual area	Post-operative pain	Decreased post-operative pain

Table 7. The Summary of Previous Studies of Dexamethasone

Authors

Year

Type of steroid

Administration

Parameter measurement

Results

NA: unknown; HRQOL: health-related quality of life; IV: intravenous.

Baxendale et al [15]

1993

8 mg dexamethasone

Oral

Post-operative pain: 4 h post-operative reduction

Significant reduction in pain 4 h post-operatively

Tiwana et al [12]

2005

NA corticosteroids and without antibiotics, no corticosteroids

Intravenous before surgery

Effect on health-related quality of life outcomes

IV corticosteroid administration had a limited, but beneficial effect on HRQOL outcomes

Grossi et al [6]

2007

4 and 8 mg dexamethasone

Submucosal injection before surgery

Post-operative edema

Significant reduction when 4 mg dexamethasone was given, but 8 mg provided no further benefit

Filho et al [2]

2008

4 and 8 mg dexamethasone

The consumption of 4 mg versus 8 mg before surgery

Swelling, trismus, pain

Better for swelling and trismus but not effective for pain

Mojsa et al [8]

2011

4 mg dexamethasone

4 mg injection, the “before” group, placebo group, the “after” group

Facial swelling, post-operative pain, trismus

Better control of pain, swelling, trismus

Antonio et al [9]

2011

8 mg dexamethasone

The oral administration, local injection in the masseter muscle

Pain, edema, limited mouth opening

Reducing post-operative pain, edema, trismus

Tiigimae-Saar et al [11]

2011

Single dose of 30 mg prednisolone, 120 mg etorikoxib

Prednisolone immediate before operation, etorikoxib 30 min before operation

Pain, facial swelling, trismus

Well-suited for treatment of post-operative pain, trismus, swelling, diminishing post-operative swelling of soft tissues

Chaurand-Lara and Facio-Umana [10]

2013

20 mg of methylprednisolone

Intramuscular in masseter and no administer

Swelling, pain

Decrease and an effective therapeutic reduction of swelling and pain

Bauer et al [14]

2013

NA ibuprofen or placebo, NA ibuprofen + dexamethasone, placebo

Pre-emptive analgesia

Post-operative pain

Pre-emptive analgesia insufficient to inhibit central sensitization, association with dexamethasone more effective

Li et al [16]

2013

4 mg and 8 mg dexamethasone

Injection of 4 - 5 mg in pericoronal injection

Post-operative swelling, trismus

Control facial swelling, trismus

Latt et al [17]

2016

Dexamethasone 8 mg, saline group

Pterygomandibular space injection

Post-operative pain

Decreased post-operative pain

Gozali et al [18]

2017

8 mg dexamethasone, saline group

Injection into sublingual area

Post-operative pain

Decreased post-operative pain