Int. J. Oral Maxillofac. Surg.

2012; 41: 376379

doi:10.1016/j.ijom.2011.12.014, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

Effect of single dose

preoperative intramuscular
dexamethasone injection on
lower impacted third molar
surgery

Boworn Klongnoi,
Pariya Kaewpradub,
Kiatanant Boonsiriseth,
Natthamet Wongsirichat
Department of Oral & Maxillofacial Surgery,
Faculty of Dentistry, Mahidol University,
Thailand

Boworn Klongnoi, Pariya Kaewpradub, Kiatanant Boonsiriseth, Natthamet

Wongsirichat: Effect of single dose preoperative intramuscular dexamethasone
injection on lower impacted third molar surgery. Int. J. Oral Maxillofac. Surg. 2012;
41: 376379. # 2011 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.
Abstract. This study aimed to investigate the effects of dexamethasone intramuscular
injection 1 h preoperatively, in reducing facial swelling, pain and trismus after
lower impacted third molar (LITM) surgery. Twenty healthy Thai patients with both
LITM surgical extraction were enrolled in the study. The washout period was 1
month after the first operation. Clinical assessment of the facial swelling, pain and
trismus were measured before and after operation for 7 days and the patients total
analgesic consumption was recorded. The level of significance used in the statistical
decisions was P < 0.05. Preoperative intramuscular injection of single-dose 8 mg
dexamethasone reduced postoperative swelling after LITM surgical extraction
significantly on the second postoperative day, but immediately after surgery and on
day 7 after the surgical extraction, no significant difference was found between the
dexamethasone and control groups. Dexamethasone also reduced postoperative
pain after LITM surgical extraction significantly on postoperative days 2 and 7.
Additionally, the amount of paracetamol decreased significantly. There were no
significant differences in trismus in the study and control groups 7 days after LITM
operation. Single-dose intramuscular injection of dexamethasone can reduce
postoperative facial swelling and pain, without affecting trismus after LITM
surgical extraction.

Lower impacted third molar (LITM) surgical extraction usually causes complications such as dysaesthesia, severe
infection, bone fracture and dry
socket3. It may also cause facial swelling
and severe pain that may seem important
0901-5027/030376 + 04 $36.00/0

to patients. Previous studies2,12,13

have reported that dexamethasone, a
well-known corticosteroid, attenuated
the inflammatory mediators released
from injury tissue and white blood
cells1.

Keywords: dexamethasone; lower impacted

third molar; pain; facial swelling; visual analogue scale; surgical extraction; postoperation..
Accepted for publication 1 December 2011
Available online 28 December 2011

SKJELBRED and LKKEN11 studied the

effect of a single intramuscular preoperative injection of 9 mg betamethasone on
postoperative pain and swelling in bilateral LITM surgical extraction. Others
have used corticosteroids peri-operatively.

# 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Dexamethasone injection in impacted third molar surgery

In 2000, ALEXANDER et al.1 reviewed the
literature on the use of cortisone, hydrocortisone, methylprednisolone, dexamethasone and betamethasone in dental
surgery, reducing the release of cortisol,
migration inhibiting factor, b-endorphins
and inflammatory tissue mediators
(lymphokines, prostaglandins, serotonin
and bradykinin) from injured tissue. Facial
swelling was decreased; the decrease in bendorphins increased the level of pain.
GRAZIANI et al.6 studied postoperative
pain and facial swelling, using 10 mg
submucosal dexamethasone, 4 mg and
10 mg endo-alveolar powder, all given
peri-operatively. GROSSI et al.7 studied
the effect of submucosal administration
of dexamethasone on discomfort after
mandibular third molar surgery. Studies
on dexamethasone consumption10 noted a
decrease in trismus and facial swelling.
FILHO et al.5 studied the effects of preoperative dexamethasone (4 and 8 mg)
consumption, to decrease pain, facial
swelling and trismus. Dexamethasone of
8 mg was more effective than that of 4 mg
at reducing facial swelling and trismus.
Many types, dosages and times of
administration have been studied for dexamethasone, but no study of 1 h singledose preoperative intramuscular injection
of dexamethasone has been undertaken.
Dexamethasone4 can reduce inflammation, especially following intramuscular
injection. This study aimed to investigate
the effects of intramuscular injection of
8 mg dexamethasone, given 1 h preoperatively, in reducing facial swelling, pain
and trismus (mouth opening limitation)
after LITM surgery.

injected intramuscularly into the deltoid

muscle 1 h before the operation. Two
millilitres of normal saline was used in
the control group. The washout period was
1 month after the first operation, and the
surgical extractions were undertaken by
the same surgeon.
This study was approved and accepted
as a clinical study protocol by the Mahidol
University Institutional Review Board
with Protocol No. MU-IRB 2010/
281.0810. All examinations and treatment
were performed with the signed consent of
the patients in the presence of a witness.
Written consent was also obtained from
the patients to present the study findings.
The LITM patients were given 1 g
amoxicillin 1 h before surgery. The length
of their faces was measured using the
reference points: inferior border of earlobe
to corner of the mouth; inferior border of
earlobe to soft tissue pogonion; and lateral
corner of the eye to angle of the mandible6
(Fig. 1). Pain levels were measured using a
visual analogue scale and the maximum
interincisal distance was also evaluated.
Surgery was performed under local
anaesthesia using the same technique: triangular flap elevation, some buccal bone
removal with tooth division and wound
closure by interrupted suture14. The postoperative medication for both groups was
500 mg amoxicillin four times a day for 5
days, and 1 g paracetamol every 46 h as
needed, but did not exceed 4 g per day.
The patients recorded their analgesic

(paracetamol) consumption each day for

7 days postoperatively.
Immediately after the surgery and on
postoperative days 2 and 7, facial swelling
(measured by increase in the length of the
face), pain levels and the interincisal distance were measured. The data were
analysed statistically, using Statistical
Package for the Social Sciences (SPSS),
by means of analytical statistics and the
Wilcoxon signed ranks test, with the level
of significance set at P < 0.05.
Results

This study showed no postoperative infection and no complications from intramuscular injection of 8 mg dexamethasone.
No significant difference was found for
surgical times between the groups. Dexamethasone significantly reduced postoperative facial swelling after LITM
surgical extraction. The difference was
not significant immediately after LITM
surgical extraction but on postoperative
day 2 a significant difference was found
between the dexamethasone and control
groups in facial swelling; no significant
difference was observed on postoperative
day 7 (Table 2).
This study showed no significant difference between the groups in pain, measured
by visual analogue scale, immediately
after LITM surgical extraction, but dexamethasone was significantly effective in
reducing pain on postoperative days 2 and

Materials and methods

20 consecutive Thai patients (6 males and

14 females) were studied. They were 19
35 years (average 21 years) of age with no
underlying disease and no history of any
drug allergy with bilateral LITM in similar
positions (Table 1), in whom LITM surgical extraction with bone removal and
tooth division was indicated. Patients were
randomized for the first operation, the
study and control groups used doubleblinded randomized sampling. Eight milligrams of (2 ml) dexamethasone was
Table 1. Type of bilateral LITM in similar
positions in this study.
Type of LTM

Number

Horizontal LITM
Distoangular LITM
Mesioangular LITM
Difficult vertical LITM

10
1
7
2

377

Fig. 1. Reference lines for facial length measurement.

378

Klongnoi et al.

Table 2. Facial swelling (increase in face length after surgery) immediately and on days 2 and 7 after LITM operation.
Time of facial swelling measurements (mm)

Dexamethasone group

Normal saline solution group

Mean

Mean

Immediately postoperation
Day 2 postoperation
Day 7 postoperation

Std. deviation

4.8
8.0
2.8

3.02
5.49
3.5

6.4
16.35
7

p-Value

Std. deviation
5.58
15.37
9

0.48
0.02
0.09

Significance level: p < 0.05.

Table 3. VAS of patients pain level immediately and on postoperative days 2 and 7.
Time of pain measurement VAS (mm)
Immediately postoperation
Day 2 postoperation
Day 7 postoperation

Dexamethasone group

Normal saline solution group

Mean

Mean

Std. deviation

2.29
1.24
0.41

2.33
1.50
0.84

2.9
3.38
1.64

p-Value

Std. deviation
3.4
2.74
2.36

0.744
0.001
0.038

Significance level: p < 0.05.

Table 4. Total of mean analgesics consumption over 7 days in each group.

Amount (tablets)
Paracetamol consumption

Dexamethasone group

Normal saline solution group

Mean

Mean

Std. deviation

6.5

7.4

p-Value

Std. deviation

10.3

11.35

0.03

Significance level: p < 0.05.

7 (Table 3). Pain was also evaluated from

the total paracetamol consumption. Fewer
analgesics were consumed by those who
received dexamethasone rather than saline
(Table 4).
There were no significant differences
between the dexamethasone and control
groups on the maximum interincisal distance preoperatively, immediately after
surgery, and on postoperative days 2
and 7 (Table 5).
The results show that preoperative
intramuscular injection of single-dose
8 mg dexamethasone affected postoperative facial swelling and pain after LITM
surgical extraction by significantly reducing the level of facial swelling and pain,
but no significant difference in maximum
interincisal distance was observed.
Discussion

This study showed no significant difference in surgical times between the dexamethasone and control groups because

the surgeon and the position of LITM were

the same. The complications in both
groups were similar.
The authors used an intramuscular
injection of 8 mg dexamethasone 1 h
before surgery because of the onset of
the drug4. The effect of dexamethasone
takes action immediately after the traumatic effect of LITM surgery. The only
disadvantage is that patients must wait at
least 1 h before the operation. This study
also showed no side effects from 8 mg
dexamethasone intramuscular injection.
The authors prescribed antibiotics
(500 mg amoxicillin) 1 h before surgery
and for 5 days after surgery to prevent
postoperative wound infection from the
LITM surgery. This study needed bone
removal with tooth division, which was
invasive surgery. It led to exposure of
cancellous marrow and the intraoral wound
fell into the clean contaminated wound
category. Both of these can cause postoperative wound infection, which although
it does not occur often, and is usually not

life threatening, makes the complete treatment cost higher. The cost of antibiotics in
the authors country is not high. The authors
did not aim to prevent adverse infection
effects from dexamethasone.
Many studies have used dexamethasone
in dentoalveolar surgery to reduce facial
swelling, pain and trismus. Many types,
dosages and times of administration have
been studied for dexamethasone1,6,7,10,9,8,
but no study of 1 h single-dose preoperative intramuscular injection of dexamethasone has been undertaken.
The results for facial swelling showed
that dexamethasone decreased postoperative facial swelling in LITM surgical
extraction, as reported in a previous
review1 by reducing the release of lymphokines, prostaglandins, serotonin and
bradykinin from injured tissue. FILHO
et al.5 reported a decrease in facial swelling on day 2 after operation using 4 and
8 mg dexamethasone, given preoperatively; 8 mg was more effective than
4 mg dexamethasone.

Table 5. Mean maximum mouth opening (interincisal distance) before surgery, immediately, and on postoperative days 2 and 7.
Time of measurement

Dexamethasone group
Mean (mm)

Preoperation
Immediately postoperation
Day 2 postoperation
Day 7 postoperation
Significance level: p < 0.05.

45.5
45.2
45.2
45.4

Normal saline solution group

Std. deviation
4.35
4.42
4.27
4.22

Mean (mm)
46
45.3
43.5
45.6

p-Value

Std. deviation
4.29
4.3
4.21
4.30

0.38
0.47
0.12
0.47

Dexamethasone injection in impacted third molar surgery

The results for postoperative pain agree
with previous studies6,7,5,9; dexamethasone was significantly more effective in
reducing pain on postoperative days 2 and
7 compared with normal saline solution.
Fewer analgesics were consumed by those
who received dexamethasone. The effect
of pain reduction is caused by inhibiting
the release of mediators (lymphokines,
prostaglandins, serotonin and bradykinin)
from injured tissue1.
Many studies have shown that pain
decrease with dexamethasone, but a clear
pathway for this effect has not been
explained. The authors suggest that the
swelling made the tissue tense and caused
tension pain that was reduced when dexamethasone decreased the facial swelling.
Eight milligrams of dexamethasone intramuscularly, 1 h before surgery significantly
reduced postoperative swelling on day 2,
when most swelling occurs. The significant
swelling reduction probably led to
decreased tissue tension related to pain.
The authors found no significant difference between the dexamethasone and control groups on the maximum interincisal
distance preoperatively, immediately after
the surgery, or on postoperative days 2 and
7; this differs from the studies of SCHMELZEI LICH10 and MESSER and KELLER8.
SEN and FRO
In conclusion, preoperative intramuscular injection of a single dose of 8 mg
dexamethasone was effective in significantly reducing pain on postoperative days
2 and 7. Dexamethasone can reduce postoperative swelling and pain after LITM
surgical extraction, but dexamethasone
does not affect trismus after LITM surgical extraction.

Funding

None.

Competing interests

None declared.

Ethical approval

The Mahidol University Institutional

Review Board with Protocol No. MUIRB 2010/281.0810.
Acknowledgements. The authors would
like to thank the patients who participated
in this study. The Surgery Department,
Faculty of Dentistry, Mahidol University
should be thanked for supporting the
patients in this study, moreover the Radiology Department, Faculty of Dentistry,
Mahidol University, should be thanked for
providing the patients panoramic radiographs. The authors would like to thank
the fourth year dental students, who collected data and related articles in the final
preparation of the manuscript. Finally, the
authors would like to thank Mr. Thomas
McManamon for revising the language of
this manuscript.
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Address:
Natthamet Wongsirichat
Department of Oral & Maxillofacial Surgery
Faculty of Dentistry
Mahidol University
6 Yothee Street
Rachathevee
Bangkok 10400
Thailand
Tel: +66 22036511 3; Fax: +66 22036495
E-mail: dtsrp@mahidol.ac.th