Ketorolac and Dexamethasone Injection Comparison on Postoperative-Pain in Impacted Mandibular Third Molars Surgery in Pterygomandibular Space: A Randomized Clinical Trial

Elham Farokh-Gisour; Saeed Hajmohamadi; Mahboobeh Shokrizadeh; Sina Yousefnia Shahrbabaki; Homa Kamyabi

Authors

Elham Farokh-Gisour
Saeed Hajmohamadi
Mahboobeh Shokrizadeh
Sina Yousefnia Shahrbabaki
Homa Kamyabi

Keywords:

Steroids, Indomethacin, Mandible, Molar, Third

Abstract

Objective: To compare the effects of ketorolac and dexamethasone on postoperative pain in patients who underwent impacted mandibular third molars surgery. Material and Methods: A double-anonymized clinical trial study involving 60 patients with impacted third molars. The samples were randomly divided into two groups by block randomization method: DG: Dexamethasone (8 mg) and KG: Ketorolac (30 mg). The severity of pain was assessed using the visual analog scale and Wong-Baker Faces Pain Rating Scale immediately and during the first to seventh days after the surgery. Results: Among the participants, 65% were female, and the mean age was 40.8 years. The study groups did not show a significant difference in the frequency of the two sexes or mean age (p=0.529 and p=0.214). The average pain scores were significantly greater in the DG compared to the KG during the first week (p<0.001). Conclusion: Injection of dexamethasone into the pterygomandibular space can help to decrease the postoperative pain following lower third molar surgery.

References

Sifuentes-Cervantes JS, Carrillo-Morales F, Castro-Núñez J, Cunningham LL, Van Sickels JE. Third molar surgery: Past, present, and the future. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132(5):523-531. https://doi.org/10.1016/j.oooo.2021.03.004

Gojayeva G, Tekin G, Saruhan Kose N, Dereci O, Kosar YC, Caliskan G. Evaluation of complications and quality of life of patient after surgical extraction of mandibular impacted third molar teeth. BMC Oral Health 2024; 24(1):131. https://doi.org/10.1186/s12903-024-03877-8

Gravani S, Matiatou M, Nikolaidis PT, Menenakos E, Zografos CG, Zografos G, et al. Anxiety and depression affect early postoperative pain dimensions after bariatric surgery. J Clin Med 2020; 10(1):53. https://doi.org/10.3390/jcm10010053

Periañez CAH, Diaz MAC, Bonisson PLV, Simino GPR, Barbosa MH, Mattia ALD. Relationship of anxiety and preoperative depression with postoperative pain. Texto Contexto Enferm 2020; 29:e20180499. https://doi.org/10.1590/1980-265X-TCE-2018-0499

Mekonnen ZA, Melesse DY, Kassahun HG, Flatie TD, Workie MM, Chekol WB. Prevalence and contributing factors associated with postoperative pain in pediatric patients: A cross-sectional follow-up study. Perioper Care Oper Room Manag 2021; 23:100159. https://doi.org/10.1016/j.pcorm.2021.100159

Daware SN, Balakrishna R, Deogade SC, Ingole YS, Patil SM, Naitam DM. Assessment of postoperative discomfort and nerve injuries after surgical removal of mandibular third molar: A prospective study. J Family Med Prim Care 2021; 10(4):1712-1717. https://doi.org/10.4103/jfmpc.jfmpc_280_19

Vranckx M, Fieuws S, Jacobs R, Politis C. Prophylactic vs. symptomatic third molar removal: Effects on patient postoperative morbidity. J Evid Based Dent Pract 2021; 21(3):101582. https://doi.org/10.1016/j.jebdp.2021.101582

Weckwerth GM, Dionísio TJ, Costa YM, Zupelari-Gonçalves P, Oliveira GM, Torres EA, et al. Multifocal analysis of acute pain after third molar removal. Front Pharmacol 2021; 12:643874. https://doi.org/10.3389/fphar.2021.643874

Cetira Filho EL, Carvalho FSR, de Barros Silva PG, Barbosa DAF, Pereira KMA, Ribeiro TR, et al. Preemptive use of oral nonsteroidal anti-inflammatory drugs for the relief of inflammatory events after surgical removal of lower third molars: A systematic review with meta-analysis of placebo-controlled randomized clinical trials. J Craniomaxillofac Surg 2020; 48(3):293-307. https://doi.org/10.1016/j.jcms.2020.01.016

Oliveira EM, Oliveira VB, Araújo LK, Lopes TS, Rego RO, Sampieri MBDS. Anti-inflammatory effectiveness of oral dexamethasone 4 mg on mandibular third molar surgeries: A split-mouth randomized clinical trial. J Oral Maxillofac Surg 2021; 79(5):981-988. https://doi.org/10.1016/j.joms.2021.01.003

Shaila B, Vaishnavi B, Jadhav NY. A review of ketorolac as a potential therapeutic agent. World J Pharm Res 2023; 13(1):539-560. https://doi.org/10.20959/wjpr20241-30761

Isiordia-Espinoza MA, Alonso-Castro ÁJ, Serafín-Higuera N, Castañeda-Santana DI, de la Rosa Coronado M, Bologna-Molina RE. Postoperative administration of ketorolac compared to other drugs for pain control after third molar surgery: A meta-analysis of double-blind, randomized, clinical trials. Br J Clin Pharmacol 2022; 88(6):2591-2604. https://doi.org/10.1111/bcp.15241

Brinks J, van Dijk EHC, Habeeb M, Nikolaou A, Tsonaka R, Peters HAB, et al. The effect of corticosteroids on human choroidal endothelial cells: A model to study central serous chorioretinopathy. Invest Ophthalmol Vis Sci 2018; 59(13):5682-5692. https://doi.org/10.1167/iovs.18-25054.

Boonsiriseth K, Latt M, Kiattavorncharoen S, Pairuchvej V, Wongsirichat N. Retracted: Dexamethasone injection into the pterygomandibular space in lower third molar surgery. Int J Oral Maxillofac Surg 2017; 46(7):899-904. https://doi.org/10.1016/j.ijom.2017.02.1266

Canellas JVdS, Ritto FG, Tiwana P. Comparative efficacy and safety of different corticosteroids to reduce inflammatory complications after mandibular third molar surgery: A systematic review and network meta-analysis. Br J Oral Maxillofac Surg 2022; 60(8):1035-1043. https://doi.org/10.1016/j.bjoms.2022.05.003

Candotto V, Oberti L, Gabrione F, Scarano A, Rossi D, Romano M. Complication in third molar extractions. J Biol Regul Homeost Agents 2019; 33(3 Suppl 1):169-172.

Doyle DJ, Garmon EH. American Society of Anesthesiologists classification (ASA class). StatPearls: StatPearls Publishing; 2019.

Halm M, Bailey C, St Pierre J, Boutin N, Rojo S, Shortt M, et al. Pilot evaluation of a functional pain assessment scale. Clin Nurse Spec 2019; 33(1):12-21. https://doi.org/10.1097/NUR.0000000000000416

Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983; 16(1):87-101. https://doi.org/10.1016/0304-3959(83)90088-X

Nazemizadeh M, Jalalodini A, Rezvani M, Yosefian N, Pournamdar Z, Ghalge M. The effect of foot reflexology massage on pain intensity in patients with chronic low back pain visited to physical therapy unit in Baghiathallah hospital in Tehran. CMJA 2012; 2(3):204-211. [In Persian].

Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications. J Am Coll Surg 2002; 195(5):694-712. https://doi.org/10.1016/s1072-7515(02)01491-6

Alexander RE, Throndson RR. A review of perioperative corticosteroid use in dentoalveolar surgery. Oral Surgery, Oral Med Oral Pathol Oral Radiol Endod 2000; 90(4):406-415. https://doi.org/10.1067/moe.2000.109778

Ong K, Seymour R, Chen F, Ho V. Preoperative ketorolac has a preemptive effect for postoperative third molar surgical pain. Int J Oral Maxillofac Surg 2004; 33(8):771-776. https://doi.org/10.1016/j.ijom.2004.01.020

Claseman TS, Foley WL, Davis RD, Morrison JW, Palmore CA, Murchison DF. A clinical evaluation of the analgesic efficacy of preoperative administration of ketorolac and dexamethasone following surgical removal of third molars. Anesth Prog 1998; 45(3):110-116.

Paiva-Oliveira JG, Bastos PR, Cury Pontes ER, da Silva JC, Delgado JA, Oshiro-Filho NT. Comparison of the anti-inflammatory effect of dexamethasone and ketorolac in the extractions of third molars. Oral Maxillofac Surg 2016; 20(2):123-133. https://doi.org/10.1007/s10006-015-0533-2

Akhlaghi N, Azarshab M, Akhoundi N, Meraji N. The effect of ketorolac buccal infiltration on postoperative endodontic pain: A prospective, double-blind, randomized, controlled clinical trial. Quintessence Int 2019; 50(7):540-546. https://doi.org/10.3290/j.qi.a42654

Sotto-Maior BS, Senna PM, Assis NMdSP. Corticosteroids or cyclooxygenase 2-selective inhibitor medication for the management of pain and swelling after third-molar surgery. J Craniofac Surg 2011; 22(2):758-762. https://doi.org/10.1097/SCS.0b013e318207f3fe

Dionne RA, Gordon SM, Rowan J, Kent A, Brahim JS. Dexamethasone suppresses peripheral prostanoid levels without analgesia in a clinical model of acute inflammation. J Oral Maxillofac Surg 2003; 61(9):997-1003. https://doi.org/10.1016/s0278-2391(03)00310-0

Lima TC, Bagordakis E, Falci SGM, dos Santos CRR, Pinheiro MLP. Pre-emptive effect of dexamethasone and diclofenac sodium associated with codeine on pain, swelling, and trismus after third molar surgery: A split-mouth, randomized, triple-blind, controlled clinical trial. J Oral Maxillofac Surg 2018; 76(1):60-66. https://doi.org/10.1016/j.joms.2017.06.012

Esen E, Taşar F, Akhan O. Determination of the anti-inflammatory effects of methylprednisolone on the sequelae of third molar surgery. J Oral Maxillofac Surg 1999; 57(10):1201-1206. https://doi.org/10.1016/s0278-2391(99)90486-x

Majid OW, Mahmood WK. Effect of submucosal and intramuscular dexamethasone on postoperative sequelae after third molar surgery: Comparative study. Br J Oral Maxillofac Surg 2011; 49(8):647-652. https://doi.org/10.1016/j.bjoms.2010.09.021

Moraschini V, Hidalgo R. Effect of submucosal injection of dexamethasone after third molar surgery: A meta-analysis of randomized controlled trials. Int J Oral Maxillofac Surg 2016; 45(2):232-240. https://doi.org/10.1016/j.ijom.2015.09.008

Antunes AA, Avelar RL, Neto ECM, Frota R, Dias E. Effect of two routes of administration of dexamethasone on pain, edema, and trismus in impacted lower third molar surgery. Oral Maxillofac Surg 2011;15(4):217-223. https://doi.org/10.1007/s10006-011-0290-9

Chopra D, Rehan H, Mehra P, Kakkar A. A randomized, double-blind, placebo-controlled study comparing the efficacy and safety of paracetamol, serratiopeptidase, ibuprofen and betamethasone using the dental impaction pain model. Int J Oral Maxillofac Surg 2009; 38(4):350-355. https://doi.org/10.1016/j.ijom.2008.12.013

Markiewicz MR, Brady MF, Ding EL, Dodson TB. Corticosteroids reduce postoperative morbidity after third molar surgery: A systematic review and meta-analysis. J Oral Maxillofac Sur 2008; 66(9):1881-1894. https://doi.org/10.1016/j.joms.2008.04.022

Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and nonsteroidal anti-inflammatory medication for the management of pain and inflammation after third molar surgery: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107(5):630-640. https://doi.org/10.1016/j.tripleo.2008.11.005

López Carriches C, Martínez González JM, Donado Rodríguez M. The use of methylprednisolone versus diclofenac in the treatment of inflammation and trismus after surgical removal of lower third molars. Med Oral Patol Oral Cir Bucal 2006; 11(5):E440-445.

Gozali P, Boonsiriseth K, Kiattavornchareon S, Khanijou M, Wongsirichat N. Decreased postoperative pain using a sublingual injection of dexamethasone (8 mg) in lower third molar surgery. J Dent Anesth Pain Med 2017; 17(1):47-53. https://doi.org/10.17245/jdapm.2017.17.1.47

Latt MM, Kiattavorncharoen S, Boonsiriseth K, Pairuchvej V, Wongsirichat N. The efficacy of dexamethasone injection on postoperative pain in lower third molar surgery. J Dent Anesth Pain Med 2016; 16(2):95-102. https://doi.org/10.17245/jdapm.2016.16.2.95

Mohtadi A, Nesioonpour S, Salari A, Akhondzadeh R, Masood Rad B, Aslani SM. The effect of single-dose administration of dexamethasone on postoperative pain in patients undergoing laparoscopic cholecystectomy. Anesth Pain Med 2014; 4(3):e17872. https://doi.org/10.5812/aapm.17872

Bhargava D, Sreekumar K, Deshpande A. Effects of intra-space injection of Twin mix versus intraoral-submucosal, intramuscular, intravenous and per-oral administration of dexamethasone on postoperative sequelae after mandibular impacted third molar surgery: A preliminary clinical comparative study. Oral Maxillofac Surg 2014; 18(3):293-296. https://doi.org/10.1007/s10006-013-0412-7

Ong CK, Seymour RA. An evidence-based update of the use of analgesics in dentistry. Periodontol 2000 2008; 46:143-164. https://doi.org/10.1111/j.1600-0757.2008.00225.x

Olmedo MV, Gálvez R, Vallecillo M. Double-blind parallel comparison of multiple doses of ketorolac, ketoprofen and placebo administered orally to patients with postoperative dental pain. Pain 2001; 90(1-2):135-141. https://doi.org/10.1016/s0304-3959(00)00396-1

Joshi A, Parara E, Macfarlane TV. A double-blind randomised controlled clinical trial of the effect of preoperative ibuprofen, diclofenac, paracetamol with codeine and placebo tablets for relief of postoperative pain after removal of impacted third molars. Br J Oral Maxillofac Surg 2004; 42(4):299-306. https://doi.org/10.1016/j.bjoms.2004.02.004

Aggarwal V, Singla M, Rizvi A, Miglani S. Comparative evaluation of local infiltration of articaine, articaine plus ketorolac, and dexamethasone on anesthetic efficacy of inferior alveolar nerve block with lidocaine in patients with irreversible pulpitis. J Endod 2011; 37(4):445-449. https://doi.org/10.1016/j.joen.2011.01.016

Martins-de-Barros AV, Barros AMI, Siqueira AKC, Lucena EES, Sette de Souza PH, Araújo FAC. Is Dexamethasone superior to Ketorolac in reducing pain, swelling and trismus following mandibular third molar removal? A split-mouth triple-blind randomized clinical trial. Med Oral Patol Oral Cir Bucal 2021; 26(2):e141-50. https://doi.org/10.4317/medoral.24088

Tirupathi S, Rajasekhar S, Maloth SS, Arya A, Tummalakomma P, Lanke RB. Pre-emptive analgesic efficacy of injected ketorolac in comparison to other agents for third molar surgical removal: A systematic review. J Dent Anesth Pain Med 2021; 21(1):1-14. https://doi.org/10.17245/jdapm.2021.21.1.1

Hasheminia D, Faghihian R, Mardani F. Effect of submucosal injection of ketorolac versus dexamethasone on postoperative pain after third molar surgery: A randomized clinical trial. Ain-Shams J Anesthesiol 2021; 13(58):1-7. doi:10.1186/s42077-021-00177-z