ORIGINAL RESEARCH

Year : 2012 | Volume : 23 | Issue : 6 | Page : 709-713

Comparison of the roles of serratiopeptidase and dexamethasone in the

control of inflammation and trismus following impacted third molar
surgery
K Murugesan, K Sreekumar, B Sabapathy
Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road,
Maduravoyal, Chennai, Tamil Nadu, India

Abstract
Introduction: Surgical extraction of lower 3 rd molar is the most frequent intervention in oral surgery. This procedure is
often associated with significant post operative swelling that may have both biological and social implications. Various
studies have been done using different anti inflammatory drugs to study their impact on inflammation.
Material and Methods: This study was conducted on 110 patients who had undergone surgical removal of
mandibular third molar. The subjects were divided into two groups by double blind method. In addition to post
operative swelling and pain , trismus was evaluated using two different groups of drugs.
Results: One group was administered 1 mg of dexamethazone every 8 hours for 3 days post operatively. The other
group was administered 10 mg of serratiopaptidase every 8 hours for 3 days post operatively. Swelling, pain and
trismus were assessed on the 1 st , 3 rd , 5 th and 7 th post operative days. The results of the studies were statistically
analysed.
Conclusion: The results showed dexamethazone was more effective in reduction of swelling and pain in comparison
with serratiopaptidase. Both dexamethazone and serratiopaptidase had the same effect on trismus.

Keywords: Dexamethasone, inflammation, serratiopeptidase, third molar, trismus

How
to
cite
this
article:
Murugesan K, Sreekumar K, Sabapathy B. Comparison of the roles of serratiopeptidase and dexamethasone in the
control of inflammation and trismus following impacted third molar surgery. Indian J Dent Res 2012;23:709-13
How
to
cite
this
URL:
Murugesan K, Sreekumar K, Sabapathy B. Comparison of the roles of serratiopeptidase and dexamethasone in the
control of inflammation and trismus following impacted third molar surgery. Indian J Dent Res [serial online] 2012
[cited 2015 Jan 1];23:709-13. Available from: http://www.ijdr.in/text.asp?2012/23/6/709/111243
Impacted third molar surgery is one of the most common procedures performed by maxillofacial surgeons. The
surgery involves the elevation of a soft tissue flap, followed by adequate bone guttering and odontectomy. [1] These
procedures cause a significant amount of tissue injury, leading to the release of various vasoactive chemical

mediators, which initiate the process of inflammation and repair. Bradykinin is a potent pain-producing substance. The
levels of immunoreactive bradykinin have been reported to increase three- to four-fold during oral surgery. [2] These
chemical mediators trigger the subsequent physiological processes, which include vasodilatation, vasoconstriction,
leukocyte migration, chemotaxis, and generation of pain impulses. This process of inflammation initiates the repair
and regeneration of the injured tissues. Though inflammation is a reparative process it causes significant distress due
to pain and swelling. Trismus, which is due to intramuscular inflammation, could be an associated distressing factor for
the patient. Hence, to minimize the unwanted effects of inflammation, it becomes essential to regulate the process of
inflammation.
In a study conducted by Elhag et al. for establishing the anti-inflammatory effects of dexamethasone the authors found
that the dexamethasone group had mean swelling volumes significantly lower than that of controls. [3] A study
conducted by Weber and Griffin examined the usefulness of dexamethasone for reducing the swelling seen following
orthognathic surgery and concluded that dexamethasone could cause significant reduction in postoperative
inflammation. [4] In the study conducted by Beirne and Hollander on the effect of prednisolone on pain, trismus, and
swelling after oral surgery, the authors concluded that prednisolone was more effective than the control drug for
reducing postsurgical trismus and pain. [5] A prospective study was conducted by Al-Khateeb and Nusair on the use of
serratiopeptidase for reduction of postoperative swelling, pain, and trismus after third molar surgery. [6] They concluded
that significant reduction in swelling could be achieved with the use of serratiopeptidase.

Materials and Methods

This study was carried out on 110 patients who underwent surgical extraction of mandibular third molars at the
Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Chennai, during the
period
October
2009
to
September
2011.
The patients were enrolled for the study consecutively as and when they reported to the hospital. Selected patients
were randomly allocated to either the dexamethasone group or the serratiopeptidase group, irrespective of age and
sex.
Inclusion criteria

Patients undergoing impacted third molar removal for the indications of pericoronitis or deep caries with

pulpitis, or for orthodontic reasons.

Included patients had to have the first and second molar on the side of surgery.

Exclusion criteria

Patients with genetically transmitted disorders (bleeding disorders)

Extraoral swelling with cellulitis in the area of surgery

History of any drug intake or systemic illness (e.g., hypertension, diabetes mellitus)

All patients were given full information regarding the purpose of the study and effects of the drugs used. After
obtaining consent for participation and completion of preoperative investigations, the patients were taken up for
surgery under local anesthesia. In one group, patients were given 1 mg of dexamethasone, 8 th hourly for 3 days

postoperatively and, in the other group, patients were given serratiopeptidase 10 mg, 8
postoperatively.

th

hourly for 3 days

For the preoperative measurements seven points were first marked on the face with indelible ink on the following
facial landmarks: mandibular angle, tragus, lateral canthus of eye, alar base, lip commissure, pogonion, and midpoint
of hyoid bone. With the mandibular angle as the base point, and using 3-0 silk suture to follow the contours of the
face, the linear distances to the other landmarks were noted. The sum total of all measurements was taken as the
facial size. Cheek girth was measured in millimeters using calipers by keeping one of the limbs of the calipers
intraorally at a standardized point, i.e. the lingual embrasure between the first and second mandibular molars, and the
other limb of the calipers extraorally so as to touch 1 cm above the anterio-inferior border of masseter. This
measurement was done with the mouth in the closed position. For recording the amount of mouth opening, the
interincisal distance (distance between the incisal edges of the central incisors) was measured using Vernier calipers.
The face and intraoral operative site was prepared with povidone iodine solution, and standard draping was done.
Anesthesia was secured with 2% lignocaine hydrochloride with 1:200000 adrenaline through inferior alveolar block,
lingual nerve block, and long buccal nerve block. A standard Wards incision was placed, the mucoperiosteal flap was
reflected, and the bone exposed. Bone removal was carried out with a round bur, using the guttering technique on the
buccal side and the distal aspect of the tooth, depending upon the type of impaction. Odontectomy was performed
whenever necessary to facilitate tooth removal. The tooth was delivered from the socket by an elevator. The socket
was irrigated with povidone iodine and saline after the sharp bony edges were smoothened. Complete hemostasis
was
achieved
before
wound
closure
with
3-0
silk
suture.
The follow-up was carried out on the 1 st , 3 rd , 5 th , and 7 th postoperative days. All the patients were under antibiotic
cover for 5 days with amoxicillin (orally) 500 mg 8 th hourly, and metronidazole (orally) 400 mg, 8 th hourly. For pain,
Acetaminophen
650
mg
was
prescribed,
to
be
taken
as
and
when
required.
The postoperative swelling, cheek girth, and the mouth opening were measured in the same manner as was done
preoperatively and was recorded. Pain assessment was made using a subjective visual analog scale. Mouth opening
was measured between the incisal edges of the central incisors. Statistical analysis was performed with the paired ttest
and
the
independent t-test
for
comparison
between
the
groups.

Results

The present study was aimed at evaluating the efficacy of serratiopeptidase and dexamethasone in reducing
postoperative
pain,
swelling,
and
trismus
after
removal
of
the
mandibular
third
molar.
[Table 1] and [Graph 1] show that there was a statistically highly significant swelling in both the groups (P < 0.001) on

day 1 and day 3. In the dexamethasone group, there was significant swelling on day 5, which reduced to an
insignificant one on day 7. In comparison, in the serratiopeptidase group, the swelling was highly significant on day 5
as well, but reduced suddenly to insignificant swelling on day 7. This suggests that dexamethasone has better antiinflammatory effect than serratiopeptidase.

Table 1: Comparison of mean values of facial measurements (in mm)

between
dexamethasone
and
serratiopeptidase
group
Click here to view

[Table 2] and [Graph 2] show that there was statistically significant increase in cheek girth values on day 1 and day 3 in

both the groups (P < 0.001). The increase in cheek girth was statistically nonsignificant on day 5 and day 7 in the
dexamethasone group. In the serratiopeptidase group, the dimensions remained highly significant on day 5 and was
nonsignificant on day 7. The pattern again suggests that dexamethasone has better anti-inflammatory effect than
serratiopeptidase.

Table 2: Comparison of mean cheek girth (in mm) in the

dexamethasone
and
serratiopeptidase
groups
Click here to view

[Table 3] and [Graph 3] show statistically highly significant restricted mouth opening on day 1 and day 3 (P < 0.001). In

both the dexamethasone and the serratiopeptidase groups there was statistically significant restricted mouth opening
(P < 0.012 and P < 0.019, respectively) on day 5 and insignificant restricted mouth opening (P < 0.114 and P < 0.223,
respectively) on day 7, suggesting that both the drugs were equally ineffective in relieving trismus.

Table 3: Mouth opening (in mm) in the serratiopeptidase and

dexamethasone
groups
Click here to view

[Table 4]a-d represents the degree of pain realized by the two groups of patients from day 1 to day 7. The group of

patients on dexamethasone recorded moderate pain on the first postoperative day and mild pain on the third
postoperative day, whereas the group of patients on serratiopeptidase recorded severe pain on the first postoperative
day and moderate pain on the third postoperative day. This suggests that pain control is better with dexamethasone
than with serratiopeptidase.