J Oral Maxillofac Surg

70:25-32, 2012, Suppl 1

What Strategies Are Helpful in the

Operative Management of Third Molars?
Joseph F. Piecuch, DMD, MD

Purpose: The purpose of this review was to investigate and report strategies that might improve
patient recovery after third molar (M3) surgery.
Materials and Methods: This was a literature review on various topics to identify the methods of
improving outcomes after M3 removal. Numerous topics were reviewed, including patient age, flap design,
effect of smoking, use of antibacterial rinses, pre-emptive analgesia, and the role of antibiotics and cortico-
steroids in recovery.
Results: Increased patient age appears to be a factor in a higher complication rate, but the literature is
sparse. The results of studies on flap design are contradictory, but there is no difference in long-term
periodontal health. Systematic reviews clearly show that longer periods of smoking cessation decrease
surgical complications, but few studies have addressed M3 surgery. Likewise, the role of pre-emptive
analgesia, although beneficial in a general surgical setting, has not been studied thoroughly with regard to M3
surgery. The use of chlorhexidine rinses to prevent alveolar osteitis and surgical site infection has been studied
extensively, but meta-analyses have not convincingly proved this effect. The evidence is convincing that
antibiotics decrease alveolar osteitis and surgical site infection. Similarly, it is clear that corticosteroids
decrease postoperative trismus and edema; however, the role of steroids in decreasing pain is not proved.
Conclusion: This review found various factors associated with improving recovery and minimizing
complications in M3 surgery.
© 2012 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 70:25-32, 2012, Suppl 1

In addressing the question of what strategies are help-
ful in the operative management of third molars (M3s)
at the Third Molar Multidisciplinary Conference (Oc-
tober 19, 2010; Washington, DC), the author re-
viewed numerous topics that may help decrease the
morbidity of M3 removal. Most of the topics covered
were controversial, with poor support in the litera-
ture. These included patient age, flap design, effect of
smoking, topical antibacterial rinses (chlorhexidine),
and pre-emptive analgesia. These topics are covered
briefly. Two other topics with good evidence in the
literature are examined at length: 1) antibiotic use to
Clinical Professor, Division of Oral and Maxillofacial Surgery, De-
partment of Craniofacial Sciences, University of Connecticut Health
Center, Farmington, CT.
Conflict of Interest Disclosures: None of the authors reported
any disclosures.
Address correspondence and reprint requests to Dr Piecuch:
Division of Oral and Maxillofacial Surgery, Department of Cranio-
facial Sciences, University of Connecticut Health Center, 263 Farm-
ington Avenue, Farmington, Connecticut, 06032-1720; e-mail:
jpiecuch@uchc.edu
© 2012 American Association of Oral and Maxillofacial Surgeons
0278-2391/12/7009-0$36.00/0
http://dx.doi.org/10.1016/j.joms.2012.04.027
decrease postoperative inflammatory complications,
ie, alveolar osteitis (AO) and surgical site infection
(SSI), and 2) corticosteroid (CS) use to decrease post-
operative morbidity.
Patient Age
Patient age is a factor associated with complications
after M3 surgery and with difficulties in anatomic posi-
tion, pre-existing periodontitis, and any preoperative
pathology.1 This study by Chuang et al,1 supported by
the American Association of Oral and Maxillofacial Sur-
geons, of 4,004 patients with 8,748 extracted mandibu-
lar M3s showed an overall complication rate of 16.3%.
However, “all patients who reported for at least 1 post-
operative visit were included in the study sample.” This
means that those who did not return were excluded.
Did they have complications? What was the incidence of
complications in those not seen after surgery? Further
studies in which all operated patients are examined
postoperatively are indicated.
Flap Design
Numerous investigators have evaluated flap de-
sign for M3 surgery. The most common designs are

S25
S26
the envelope flap, continued anterior to the distal
of the first molar, and the triangular flap, with a
vertical release posterior to the second molar.
Short-term study results have been contradictory.
Kirk et al2 found more swelling with the triangular
flap and no difference between the 2 flap designs in
dehiscence, pain, maximal incisal opening, and AO.
Sandhu et al3 found no difference in swelling, max-
imal incisal opening, and AO, but a significant in-
crease in dehiscence and pain with the envelope
flap. Nonetheless, investigators who studied long-
term periodontal health showed no difference be-
tween the 2 flap designs.4-6
Smoking
The role of smoking in postsurgical complica-
tions is well known. A recently published system-
atic review of the topic7 showed that longer peri-
ods of smoking cessation before and after surgery
appear to be more effective, but the optimal period
of cessation could not be identified. This analysis
examined different general surgical procedures, but
not tooth extraction. The literature on smoking and
M3 surgery is sparse. Al-Belasy8 looked specifically
at the effect of smoking on the incidence of AO
after M3 surgery. The results showed incidences of
7% in nonsmokers, 31.6% in smokers who did not
smoke the day of surgery, 17.9% in smokers who
ceased for the day of surgery and the day after, and
10.5% when the cessation also included the second
postoperative day.
Topical Antibacterial Mouth Rinses
The role of chlorhexidine rinses in the preven-
tion of AO and SSI has been studied extensively,
with literally hundreds of articles, pro and con.
Caso et al9 performed a meta-analytic review spe-
cifically of human clinical trials involving M3 sur-
gery only with random assignment to rinse and
control groups. Their analysis showed that chlo-
rhexidine alone on the day of surgery offered no
benefit. An extended rinse period of 1 week may
decrease the incidence of AO. Minguez-Serra et al10
performed a similar meta-analysis, which con-
cluded that the application of a 0.2% chlorhexidine
paste every 12 hours for 1 week after M3 surgery
decreased the incidence of AO.
Pre-Emptive Analgesia
Pre-emptive analgesia has been defined as a “phar-
macological intervention initiated prior to a painful
stimulus in order to inhibit nociceptive mechanisms
OPERATIVE MANAGEMENT OF THIRD MOLARS
before they are triggered.”11 Characteristics of pre-
emptive analgesia include11,12:
1. Starting before surgery
2. Preventing the establishment of central sensiti-
zation caused by incisional injury
3. Preventing central sensitization caused by in-
flammation
4. Involving the surgical and initial postoperative
periods
5. The effect may last at least 10 weeks
Cliff13 performed a meta-analysis of the efficacy of
pre-emptive analgesia for acute postoperative pain
management after major general surgery. The findings
showed that local anesthetics and systemic nonsteroi-
dal anti-inflammatory drugs (NSAIDs) were effective,
whereas systemic opioids were not. Nayyar and
Yates14 performed a randomized controlled trial
(RCT) of the pre-emptive effects of bupivacaine on
M3 surgery. Bilateral M3 removal was performed un-
der general anesthesia. Bupivacaine 0.5% with epi-
nephrine 1:200,000 was used on 1 side and nothing
on the other. This study found a significant decrease
in pain at the bupivacaine surgical site at 6, 12, 72
hours and 7 days. No other study of local anesthesia
and M3 surgery has extended beyond 24 hours. The
effects of tramadol15 and ketoprofen16 versus placebo
for M3 surgery were found to be significant, but these
studies were concluded at 24 and 12 hours, respec-
tively. In conclusion, pre-emptive local anesthesia is
effective in M3 surgery. However, the effect of
NSAIDs requires more study of longer-term effects.
Antibiotic Prophylaxis
In the review of this topic, a wide range of the
literature was considered, including some published
studies that are flawed. This was performed deliber-
ately, not to embarrass the investigators but to point
out deficiencies in articles that have been accepted by
prominent journals. For example, how important is a
published study of the effects of prophylactic antibi-
otics in which the antibiotic is begun after the surgery
is completed, thus violating a cardinal rule of prophy-
laxis: that the antibiotic must be in the tissue at the
time the incision is made? Alternatively, how valuable
is an oft-cited article on the incidence of postopera-
tive sequelae in which the investigators state that not
all of the patients were examined after the surgery?
The role of antibiotics in the prevention of inflam-
matory complications after M3 surgery has long been
debated.17,18 Fifty years ago, the “standard treatment
plan” for pericoronitis involved 2 stages.19 The first
stage included irrigation, insertion of a caustic mate-
rial such as trichloroacetic acid into the “pericoronal
JOSEPH F. PIECUCH S27

Table 1. INFECTION RATES REPORTED IN

ducted an RCT of postoperative bacterial growth
THE LITERATURE within the extraction sockets and found a significant
decrease in patients who were on penicillin. Two
Teeth Infections Infections large retrospective studies found a much lower over-
Study (n) (n) (%)
all incidence of postoperative infection26,27; however,
Curran et al20 133 11 8.2 all patients were not examined after surgery, leading
Happonen et al21 136 16 11.8 this reader to conclude that the studies were flawed.
Nordenram et al23 143 18 12.6 These studies, although often cited at the time, did
Mitchell24 99 24 27.0
not distinguish between the use and nonuse of anti-
Mitchell and Morris25 172 19 11.0
Goldberg et al22 500 21 4.2 biotic prophylaxis.
Osborn et al26 16,127 553 3.4 In contrast, in 1995, there was strong support in
Sisk et al27 1,202 14 1.2 the literature for the prevention of AO by the use of
Note: From Piecuch et al.17 antibiotics placed directly into the socket during sur-
gery.23,30-33
Joseph F. Piecuch. Operative Management of Third Molars. J Oral
Maxillofac Surg 2012.
Analysis of the Author’s Patients
pouch,” warm saline mouth rinses “as hot as can be A retrospective analysis of the author’s patients,
tolerated without scalding,”19 extraction of the op- published in 1995,17 showed that in a 9-year period
posing tooth, and possibly antibiotics. The final stage, 2,134 patients underwent extraction of 6,713 M3s. Of
performed after infection had been controlled, was these, 2,031 patients were examined on average 7 to
the extraction of the involved tooth. The 1966 study 10 days after surgery. The other 103 were not seen,
by Kay19 showed that the extraction of M3s in the but each had extensive chart notes from telephone
presence of infection without antibiotics resulted in a calls documenting the lack of symptoms at 48 hours
71% incidence of AO versus 8% when antibiotics were and at 7 days; thus, they were included.
used. This study also reported on M3 extraction in Of 3,270 maxillary M3s, the overall infection rate
2,265 patients after infection was controlled. The was 9/3,270 (0.3%). Of 3,443 mandibular M3s, the
1,341 patients treated without an antibiotic cover had overall infection rate was 6.6%. The incidence of
an incidence of AO of 24%. The 924 other patients severe infection requiring hospitalization, intravenous
who underwent M3 extraction with an antibiotic antibiotics, or external incision and drainage was 0.
cover (preoperatively) had an incidence of AO of When examining only mandibular M3s, those treated
2.9%. without antibiotics showed a 14.8% infection rate,
In 1995, when the author’s colleague, Dr Arzadon, those with systemic (generally oral) antibiotics a
patiently performed a review of all their patients with 10.8% infection rate, those with topical tetracycline a
M3 extraction seen in the first 9 years of their prac- 2.6% infection rate, and those with tetracycline plus
tice, Piecuch et al17 concurrently reviewed the litera- systemic antibiotics a 2.4% infection rate (Table 2).
ture, finding contradictory and flawed opinions on oral When examining the results by tooth position,
or parenteral antibiotic prophylaxis (Table 1).20-27 overall incidences were 0.9% for erupted M3s, 1.6%
Curran et al,20 Happonen et al,21 Goldberg et al,22 for soft tissue impactions, 3.8% for partial bony im-
and Capuzzi et al28 each recommended against anti- pactions, and 13.9% for full bony impactions. A full
biotic prophylaxis. However, in the study by Curran bony impacted M3 extracted without antibiotic pro-
et al,20 the antibiotic group actually had a higher phylaxis had a 26.5% risk of postoperative infection; if
incidence of postoperative infection than the nonan- topical tetracycline was used, the risk decreased to
tibiotic group. Goldberg et al22 reported a 9.4% post- 6.6%. This study also looked at the incidence of AO
operative SSI without antibiotics and a 1.1% SSI with after M3 extraction. Without antibiotics, the inci-
antibiotics, yet they recommended against prophy- dence was 6.6%, and with antibiotics, it was 3.0%.
laxis. Happonen et al21 and Capuzzi et al28 saw no The investigators concluded that systemic antibiot-
difference with or without antibiotics. However, ics were of no benefit for maxillary M3s; but topical
Capuzzi et al violated a basic principle of prophylaxis tetracycline offered benefit for erupted mandibular
in that there was no antibiotic in the tissue when the M3s. Systemic antibiotics and topical tetracycline
procedure was performed. There was no preopera- were effective in decreasing postoperative infections
tive dose. for mandibular partial and full bony M3s. However,
Mitchell24 reported a 4% SSI incidence in the anti- topical tetracycline was more effective.
biotic group and a 45% SSI incidence in the placebo Some investigators have correctly raised the issue
group, and Mitchell and Morris25 subsequently con- of tetracycline-induced neuritis, occurring after tetra-
firmed these results. Krekmanov and Hallander29 con- cycline comes in contact with an exposed nerve.34
S28 OPERATIVE MANAGEMENT OF THIRD MOLARS

Table 2. MANDIBULAR INFECTIONS WITH AND WITHOUT ANTIBIOTICS

M3s Without Overall Infection

Treatment M3s (n) Infection (n) Early Infection Late Infection Rate, n (%)

No AB 332 283 45 4 49 (14.8)

Systemic AB 1,242 1,114 96 32 128 (10.3)
Topical TC 1,597 1,555 28 14 42 (2.6)
Systemic AB ⫹ TC 250 244 3 3 6 (2.4)
Postoperative systemic AB 9 8 0 1 1 (11.1)
TC ⫹ postoperative systemic AB 13 13 0 0 0 (0)
Total 3,443 3,217 172 54 226 (6.6)
Note: From Piecuch et al.17
Abbreviations: AB, antibiotic; M3s, third molars; TC, tetracycline.
Joseph F. Piecuch. Operative Management of Third Molars. J Oral Maxillofac Surg 2012.

However, the same investigators performed a pro-
spective study in rats that showed that a nerve with
an intact epineurium did not develop an inflammatory
response to tetracycline. Only if the epineurium was
damaged did an intense inflammatory response oc-
cur.35 Gelfoam placed against the damaged nerve did
not induce inflammation. This implies that an ex-
posed nerve can be protected by simply placing Gel-
foam gently over the nerve before inserting tetracy-
cline into the socket.
Recent Literature
In the years since the article by Piecuch et al17 was
published, several prospective, randomized, placebo-
controlled studies concerning the effectiveness of
prophylactic antibiotics have been published. These
are summarized in Table 3. In 1999, Monaco et al36
found no benefit from amoxicillin 2 g/day for 5 days
after surgery. However, this study violated a cardinal
principle of antibiotic prophylaxis in that no preop-
erative dose was given. This error was repeated in the
publication by Ataoğlu et al37 in 2008. Monaco et al38
repeated their study 10 years later. In this study, the
test group received amoxicillin 2 g 1 hour before
surgery, whereas the control group received no anti-
biotic. The results showed a statistically significant
decrease in infection in the study (antibiotic) group.
Poeschl et al39 showed no benefit from amoxicillin-
clavulanate potassium or clindamycin; however, they
did not use a preoperative dose, a violation of the
cardinal principle of prophylaxis.
Foy et al40 and Stavropoulos et al41 each showed an
improvement in health-related quality of life with pre-
operative intravenous antibiotics and topical intra-
socket minocycline, respectively. These articles are
products of the long-term Third Molar Clinical Trial
sponsored by the American Association of Oral and
Maxillofacial Surgeons and Oral and Maxillofacial Sur-
gery Foundation, led by Dr Raymond P. White, Jr, and
based at the University of North Carolina. A study by
Halpern and Dodson42 confirmed the benefit of pre-
operative prophylactic intravenous antibiotics in de-
creasing the frequency of surgical site infections.
These studies are summarized in Table 3.
Conversely, a recent prospective randomized, dou-
ble-masked, placebo-controlled trial43 did not find the
prevention of postoperative inflammatory complica-
tions with a preoperative single dose of clindamycin
or a preoperative dose plus a 5-day postoperative ad-
ministration. Kaczmarzyk44 subsequently published, as a
letter to the editor, a reasonable yet impassioned plea
challenging the routine use of antibiotic prophylaxis
for M3 surgery.

Table 3. RECENT ARTICLES: DO ANTIBIOTICS PROVIDE BENEFIT OR NOT?

Year Study Journal Method Benefit Preoperative AB

1999 Monaco et al36 EJOS Oral No No

2004 Poeschl et al39 JOMS Oral No No
2004 Foy et al40 JOMS IV Yes Yes
2006 Stavropoulos et al41 JOMS Topical Yes Yes
2007 Halpern and Dodson42 JOMS IV Yes Yes
2009 Monaco et al38 JOMS Oral Yes Yes
Abbreviations: AB, antibiotic; EJOS, European Journal of Oral Sciences; IV, intravenous; JOMS, Journal of Oral and
Maxillofacial Surgery.
Joseph F. Piecuch. Operative Management of Third Molars. J Oral Maxillofac Surg 2012.
JOSEPH F. PIECUCH
In 2007, Ren and Malmstrom45 published an article
titled “Effectiveness of Antibiotic Prophylaxis in Third
Molar Surgery: A Meta-Analysis of Randomized Con-
trolled Clinical Trials.” This is the only published
meta-analysis on this topic, and it includes only arti-
cles comparing systemic antibiotics with placebo.
Case reports, case series, reports without a control
group, and retrospective reviews were excluded.
With respect to wound infection, 12 clinical trials
showed an SSI frequency of 6.1% in the control group
and an SSI frequency of 4% in the prophylaxis group.
With respect to AO, 16 clinical trials showed an over-
all frequency of 14.1% in the control groups and an
overall frequency of 6.2% in the antibiotic prophy-
laxis group. These investigators concluded that anti-
biotics decreased the risk of AO and SSI, but only
when the first dose was given before surgery.
In conclusion, it appears clear, despite some con-
flicting evidence, that antibiotic prophylaxis signifi-
cantly decreases the occurrence of postoperative AO
and SSI. However, the surgeon must also be cognizant
of the concerns regarding antibiotic resistance and
systemic toxicity raised by Kaczmarzyk.44 The au-
thor’s experience, using topical tetracycline avoids the
toxicity of systemic doses and yields better results than
systemic antibiotics. Thus, the author continues to use
topical antibiotics except in cases of active infection
requiring a therapeutic antibiotic dose schedule, a
medical compromise that specifically requires sys-
temic antibiotic prophylaxis, such as new total joint
prostheses, or specific cardiac conditions that fall
under American Heart Association guidelines.
Corticosteroids
The role of CSs in preventing postoperative mor-
bidity has been addressed in literally hundreds of
articles, beginning in the 1950s. Cortisone and hydro-
cortisone were first isolated in the 1930s, but it was
not until the late 1940s that Hench et al46 reported
the benefit of the exogenous steroid administration
for rheumatoid arthritis. Subsequently, numerous in-
vestigations of the efficacy of CSs in specific condi-
tions and in surgery have been published. By the early
1950s, steroids were being used as adjuncts to surgi-
cal procedures, although concerns were raised as to
potential problems with wound healing if steroids
were administered. In their review of the then current
applications of CSs in surgery, Galante et al47 stated:
“prevention of wound healing . . . is not a problem if
these agents are used no more than 5-7 days, in
decreasing doses.”
In the dental field, Shafer48 studied the effects of
cortisone on postextraction wound healing in a rat
model. Thirty-five experimental animals were given
cortisone 2.5 mg on the day of extraction of an upper
S29
molar and 2 mg/day afterward. Histologically, there
was no difference in healing versus nonmedicated
controls at 2, 4, 5, and 7 days. However at 10 days,
soft tissue healing was impaired in the experimental
animals. Clearly, the exogenous steroid should not be
continued for long periods. Although the use of steroids
to decrease edema after oral surgery eventually became
quite common, it was not until the early 1970s that
Hooley et al49 reported that, in humans, a short course
of CSs only temporarily decreased endogenous ste-
roid production. In this study, a 3-day course of beta-
methasone decreased plasma cortisol levels, which
rebounded to normal levels within 4 days of cessa-
tion. In addition, it was not until 1980, when using a
metapyrone test, that Williamson et al50 noted that
the hypothalamic-pituitary-adrenal axis returned to
normal in 7 days in 10 consecutive patients who
received dexamethasone 8 mg intravenously immedi-
ately after oral surgical procedures.
Despite the lack of a full knowledge of the methods
of their action, in the 1950s dentists and oral-maxill-
ofacial surgeons rapidly began to use steroids, initially
in comparison with antihistamines, to decrease
edema and postoperative discomfort.51-54 Some inves-
tigators noticed a degree of “rebound” swelling when
the steroid was discontinued52; the method of evalu-
ation of edema in these early studies was the simple
clinical observation of “less than expected,” “ex-
pected,” and “more than expected.”
Nevertheless, many were skeptical. In his 10-page
1958 review, “Control of Postoperative Edema,”
Hinds55 discussed at length surgical techniques, anti-
biotics, antihistamines, and enzymes, such as hyaluron-
idase, streptokinase, and trypsin. However, he dismissed
CSs with the comment, “cortisone in most instances is
probably contraindicated.” However, in the very next
issue of the same journal, Ross and White56 presented
the results of their RCT. Thirty-nine oral surgical pa-
tients were given hydrocortisone 40 mg 2 times/day
the day before surgery, 4 times/day the day of surgery,
and 2 times/day for 2 days after surgery. Twenty-two
patients were given placebo according to the same
dose schedule. The investigators noted a statistically
significant decrease in edema and trismus in the ex-
perimental group. Pain also was less in the experi-
mental group, but the difference was not statistically
significant.
Nathanson and Seifert57 reported on the effects of
betamethasone in their prospective RCT in 1964. One
hundred ten patients received betamethasone 0.6 mg
4 times/day for 4 days beginning immediately postop-
eratively, whereas 100 control patients received pla-
cebo. All were examined each day for 5 days by 1 of
the investigators. The findings included a significant
decrease in edema in the experimental group, a trend
to decreased pain in the experimental group, and no
S30
difference in trismus. Because the investigators noted
initial edema before the first dose was given, which
resolved after that dose, their recommendation was
modified to initiate the drug the day before surgery
and to continue 3 days postoperatively. Various sur-
gical procedures were performed for these patients.
Hooley and Francis58 used the dose recommendations
of Nathanson and Seifert for their prospective RCT of
476 patients who underwent surgical extraction of an
impacted mandibular M3. The patients served as their
own controls, returning later for the opposite-side
surgery by the same surgeon. For the experimental
side, they received 2 tablets of betamethasone 0.6 mg
the evening before surgery and then 2 tablets of 0.6
mg 4 times/day the day of surgery and 2 tablets 4
times/day for the next 2 days. Tetracycline cones
were placed into each extraction socket. These inves-
tigators were the first to use cephalometrically posi-
tioned photographs for the objective measurement of
edema. Their findings showed that the controls had 6
times as much edema, 2 times as much trismus, and
required 2 times as much pain medication as the
controls. These investigators commented that they
had used betamethasone for more than 2,000 patients
in the previous 8 years without any systemic compli-
cations.
Over the course of the next 30 years, numerous
articles have appeared comparing various steroids
with placebo, including triamcinolone,59 dexametha-
sone,60-62 prednisone,63 methylprednisolone,64-66 and
betamethasone.67
The details of each of these studies were thor-
oughly discussed in a 1992 review by Gersema and
Baker68 and will not be repeated here. Although al-
most all of these studies were prospective RCTs,
many also had small subject numbers, inconsistent
procedures, and subjective observations of results.
Nevertheless, Gersema and Baker concluded that
“based on these studies, the use of perioperative CSs
appears to be a safe and rational method of decreasing
postoperative complications of edema, and possibly
trismus and pain, after the removal of impacted
M3s.”68 These investigators recommended a single
preoperative dose of methylprednisolone 125 mg
given intravenously or intramuscularly.
Most recently, several interesting articles have ap-
peared that examine previously undiscussed parame-
ters or combinations of drugs. Tiwana et al69 prospec-
tively compared 60 patients who received preoperative
CSs (dexamethasone 8 mg or methylprednisolone 40
mg) with 60 similar control patients who did not
receive CSs. No patients in either group received
antibiotics. All patients in the 2 groups were consid-
ered to have higher than average risk for postopera-
tive sequelae because all had 4 M3s below the occlu-
sal plane. In this study, patients filled in a daily log,
OPERATIVE MANAGEMENT OF THIRD MOLARS
and those who did not return were questioned by
telephone. Because objective measurements were not
performed by the clinicians, there were no statisti-
cally significant differences found in edema, mouth
opening, or pain. However, there was significantly
improved sleep in the CS group at days 1 to 4 and
decreased nausea on day 1 in the CS group. Postop-
erative visits with treatment (placement of dressings,
debridement, or antibiotic prescription) occurred in
28% of the control group and in 10% of the CS group.
Suture removal and irrigation were not considered
treatment.
In a prospective RCT, Buyukkurt et al70 compared
prednisolone 25 mg intramuscular, prednisolone 25
mg plus diclofenac intramuscular, and control (saline
placebo intramuscular), all given immediately after
M3 surgery. There were 15 patients in each group.
Pain intensity was measured on a visual analog scale,
and edema was measured objectively in patients on
days 2 and 7. These investigators found significantly
decreased edema and trismus at days 2 and 7 in the
prednisolone and prednisolone-diclofenac groups ver-
sus the control group. Pain was studied only on the
day of surgery and was significantly decreased in the
prednisolone and prednisolone-diclofenac groups,
with the prednisolone-diclofenac combination being
more effective. These investigators recommended a
steroid/NSAID combination as more effective than
steroid alone. Hyrkäs et al71 previously performed the
reverse comparison, comparing diclofenac alone with
the methylprednisolone-diclofenac combination, and
found the combination produced better pain control
than diclofenac alone.
This potentially synergistic effect of steroid plus
NSAID versus control was investigated in a model of
acute inflammation by Dionne et al.72 In this prospec-
tive RCT, there were 3 groups: 1) preoperative dexa-
methasone/postoperative ketorolac; 2) preoperative
dexamethasone/postoperative saline placebo; and 3)
preoperative saline placebo/postoperative saline pla-
cebo.
The steroid was administered 4 mg orally at 12
hours before surgery and 4 mg intravenously 1 hour
before surgery. The postoperative dose of ketorolac
30 mg or saline placebo was given at pain onset,
usually about 2 hours after the procedure. There was
no difference in pain onset in the dexamethasone and
control groups. The pain decrease was significant in
the dexamethasone/ketorolac group only. There was
no difference in pain between the steroid/placebo
and placebo/placebo groups. Unfortunately, these in-
vestigators did not compare the dexamethasone/ke-
torolac group with another placebo/ketorolac group.
Thus, whether the combination of steroid and ketoro-
lac is more, less, or equally effective as ketorolac
alone was not studied.
JOSEPH F. PIECUCH
Markiewicz et al73 published their study, “Cortico-
steroids Reduce Postoperative Morbidity After Third
Molar Surgery: A Systematic Review and Meta-Analy-
sis,” in 2008. The investigators asked 1 simple ques-
tion: “Among patients undergoing M3 removal, does
perioperative CS administration, when compared
with similar control, decrease postoperative edema,
trismus, and pain in the early (1-3 days) and late (⬎3
days) postoperative periods?” The study criteria in-
cluded English-language publications, a prospective
clinical trial, reported descriptive statistics, and, if
reporting pain, a visual analog scale. These investiga-
tors initially identified 599 articles on the topic, but
most did not meet the inclusion criteria, because they
were retrospective, reviews, case reports, letters to
the editor, or did not involve human subjects. Only 12
of these articles yielded extractable data. This illus-
trates the relative absence in the literature of objec-
tive data on this important topic.
The data reported by Markiewicz et al73 confirmed
that CSs decrease edema and trismus in the early and
late postoperative periods. In terms of pain, even
fewer articles qualified for analysis because most arti-
cles focused on number of analgesic doses and on
analgesic dosage rather on the visual analog scale.
Consequently, although CSs appeared to decrease
pain in the early postoperative period, this finding
was not statistically significant.
In conclusion, despite a plethora of articles on the
various topics covered in this review, there is actually
very little definitive information available. There does
appear to be a consensus that prophylactic antibiotics
and CSs are of benefit in decreasing complications
and in improving the postoperative quality of life after
M3 surgery. The most interesting area for future re-
search is in the area of pre-emptive analgesia, al-
though more long-term studies specifically regarding
M3 surgery are needed.
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