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

S25
S26 OPERATIVE MANAGEMENT OF THIRD MOLARS

the envelope flap, continued anterior to the distal before they are triggered.”11 Characteristics of pre-
of the first molar, and the triangular flap, with a emptive analgesia include11,12:
vertical release posterior to the second molar.
Short-term study results have been contradictory. 1. Starting before surgery
Kirk et al2 found more swelling with the triangular 2. Preventing the establishment of central sensiti-
flap and no difference between the 2 flap designs in zation caused by incisional injury
dehiscence, pain, maximal incisal opening, and AO. 3. Preventing central sensitization caused by in-
Sandhu et al3 found no difference in swelling, max- flammation
imal incisal opening, and AO, but a significant in- 4. Involving the surgical and initial postoperative
crease in dehiscence and pain with the envelope periods
flap. Nonetheless, investigators who studied long- 5. The effect may last at least 10 weeks
term periodontal health showed no difference be-
tween the 2 flap designs.4-6 Cliff13 performed a meta-analysis of the efficacy of
pre-emptive analgesia for acute postoperative pain
management after major general surgery. The findings
Smoking showed that local anesthetics and systemic nonsteroi-
The role of smoking in postsurgical complica- dal anti-inflammatory drugs (NSAIDs) were effective,
tions is well known. A recently published system- whereas systemic opioids were not. Nayyar and
atic review of the topic7 showed that longer peri- Yates14 performed a randomized controlled trial
ods of smoking cessation before and after surgery (RCT) of the pre-emptive effects of bupivacaine on
appear to be more effective, but the optimal period M3 surgery. Bilateral M3 removal was performed un-
of cessation could not be identified. This analysis der general anesthesia. Bupivacaine 0.5% with epi-
examined different general surgical procedures, but nephrine 1:200,000 was used on 1 side and nothing
not tooth extraction. The literature on smoking and on the other. This study found a significant decrease
M3 surgery is sparse. Al-Belasy8 looked specifically in pain at the bupivacaine surgical site at 6, 12, 72
at the effect of smoking on the incidence of AO hours and 7 days. No other study of local anesthesia
after M3 surgery. The results showed incidences of and M3 surgery has extended beyond 24 hours. The
7% in nonsmokers, 31.6% in smokers who did not effects of tramadol15 and ketoprofen16 versus placebo
smoke the day of surgery, 17.9% in smokers who for M3 surgery were found to be significant, but these
ceased for the day of surgery and the day after, and studies were concluded at 24 and 12 hours, respec-
10.5% when the cessation also included the second tively. In conclusion, pre-emptive local anesthesia is
postoperative day. effective in M3 surgery. However, the effect of
NSAIDs requires more study of longer-term effects.

Topical Antibacterial Mouth Rinses Antibiotic Prophylaxis


The role of chlorhexidine rinses in the preven- In the review of this topic, a wide range of the
tion of AO and SSI has been studied extensively, literature was considered, including some published
with literally hundreds of articles, pro and con. studies that are flawed. This was performed deliber-
Caso et al9 performed a meta-analytic review spe- ately, not to embarrass the investigators but to point
cifically of human clinical trials involving M3 sur- out deficiencies in articles that have been accepted by
gery only with random assignment to rinse and prominent journals. For example, how important is a
control groups. Their analysis showed that chlo- published study of the effects of prophylactic antibi-
rhexidine alone on the day of surgery offered no otics in which the antibiotic is begun after the surgery
benefit. An extended rinse period of 1 week may is completed, thus violating a cardinal rule of prophy-
decrease the incidence of AO. Minguez-Serra et al10 laxis: that the antibiotic must be in the tissue at the
performed a similar meta-analysis, which con- time the incision is made? Alternatively, how valuable
cluded that the application of a 0.2% chlorhexidine is an oft-cited article on the incidence of postopera-
paste every 12 hours for 1 week after M3 surgery tive sequelae in which the investigators state that not
decreased the incidence of AO. 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
Pre-Emptive Analgesia
debated.17,18 Fifty years ago, the “standard treatment
Pre-emptive analgesia has been defined as a “phar- plan” for pericoronitis involved 2 stages.19 The first
macological intervention initiated prior to a painful stage included irrigation, insertion of a caustic mate-
stimulus in order to inhibit nociceptive mechanisms 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- decrease in infection in the study (antibiotic) group.
spective study in rats that showed that a nerve with Poeschl et al39 showed no benefit from amoxicillin-
an intact epineurium did not develop an inflammatory clavulanate potassium or clindamycin; however, they
response to tetracycline. Only if the epineurium was did not use a preoperative dose, a violation of the
damaged did an intense inflammatory response oc- cardinal principle of prophylaxis.
cur.35 Gelfoam placed against the damaged nerve did Foy et al40 and Stavropoulos et al41 each showed an
not induce inflammation. This implies that an ex- improvement in health-related quality of life with pre-
posed nerve can be protected by simply placing Gel- operative intravenous antibiotics and topical intra-
foam gently over the nerve before inserting tetracy- socket minocycline, respectively. These articles are
cline into the socket. products of the long-term Third Molar Clinical Trial
sponsored by the American Association of Oral and
Maxillofacial Surgeons and Oral and Maxillofacial Sur-
Recent Literature
gery Foundation, led by Dr Raymond P. White, Jr, and
In the years since the article by Piecuch et al17 was based at the University of North Carolina. A study by
published, several prospective, randomized, placebo- Halpern and Dodson42 confirmed the benefit of pre-
controlled studies concerning the effectiveness of operative prophylactic intravenous antibiotics in de-
prophylactic antibiotics have been published. These creasing the frequency of surgical site infections.
are summarized in Table 3. In 1999, Monaco et al36 These studies are summarized in Table 3.
found no benefit from amoxicillin 2 g/day for 5 days Conversely, a recent prospective randomized, dou-
after surgery. However, this study violated a cardinal ble-masked, placebo-controlled trial43 did not find the
principle of antibiotic prophylaxis in that no preop- prevention of postoperative inflammatory complica-
erative dose was given. This error was repeated in the tions with a preoperative single dose of clindamycin
publication by Ataoğlu et al37 in 2008. Monaco et al38 or a preoperative dose plus a 5-day postoperative ad-
repeated their study 10 years later. In this study, the ministration. Kaczmarzyk44 subsequently published, as a
test group received amoxicillin 2 g 1 hour before letter to the editor, a reasonable yet impassioned plea
surgery, whereas the control group received no anti- challenging the routine use of antibiotic prophylaxis
biotic. The results showed a statistically significant 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 S29

In 2007, Ren and Malmstrom45 published an article molar and 2 mg/day afterward. Histologically, there
titled “Effectiveness of Antibiotic Prophylaxis in Third was no difference in healing versus nonmedicated
Molar Surgery: A Meta-Analysis of Randomized Con- controls at 2, 4, 5, and 7 days. However at 10 days,
trolled Clinical Trials.” This is the only published soft tissue healing was impaired in the experimental
meta-analysis on this topic, and it includes only arti- animals. Clearly, the exogenous steroid should not be
cles comparing systemic antibiotics with placebo. continued for long periods. Although the use of steroids
Case reports, case series, reports without a control to decrease edema after oral surgery eventually became
group, and retrospective reviews were excluded. quite common, it was not until the early 1970s that
With respect to wound infection, 12 clinical trials Hooley et al49 reported that, in humans, a short course
showed an SSI frequency of 6.1% in the control group of CSs only temporarily decreased endogenous ste-
and an SSI frequency of 4% in the prophylaxis group. roid production. In this study, a 3-day course of beta-
With respect to AO, 16 clinical trials showed an over- methasone decreased plasma cortisol levels, which
all frequency of 14.1% in the control groups and an rebounded to normal levels within 4 days of cessa-
overall frequency of 6.2% in the antibiotic prophy- tion. In addition, it was not until 1980, when using a
laxis group. These investigators concluded that anti- metapyrone test, that Williamson et al50 noted that
biotics decreased the risk of AO and SSI, but only the hypothalamic-pituitary-adrenal axis returned to
when the first dose was given before surgery. normal in 7 days in 10 consecutive patients who
In conclusion, it appears clear, despite some con- received dexamethasone 8 mg intravenously immedi-
flicting evidence, that antibiotic prophylaxis signifi- ately after oral surgical procedures.
cantly decreases the occurrence of postoperative AO Despite the lack of a full knowledge of the methods
and SSI. However, the surgeon must also be cognizant of their action, in the 1950s dentists and oral-maxill-
of the concerns regarding antibiotic resistance and ofacial surgeons rapidly began to use steroids, initially
systemic toxicity raised by Kaczmarzyk.44 The au- in comparison with antihistamines, to decrease
thor’s experience, using topical tetracycline avoids the edema and postoperative discomfort.51-54 Some inves-
toxicity of systemic doses and yields better results than tigators noticed a degree of “rebound” swelling when
systemic antibiotics. Thus, the author continues to use the steroid was discontinued52; the method of evalu-
topical antibiotics except in cases of active infection ation of edema in these early studies was the simple
requiring a therapeutic antibiotic dose schedule, a clinical observation of “less than expected,” “ex-
medical compromise that specifically requires sys- pected,” and “more than expected.”
temic antibiotic prophylaxis, such as new total joint Nevertheless, many were skeptical. In his 10-page
prostheses, or specific cardiac conditions that fall 1958 review, “Control of Postoperative Edema,”
under American Heart Association guidelines. Hinds55 discussed at length surgical techniques, anti-
biotics, antihistamines, and enzymes, such as hyaluron-
idase, streptokinase, and trypsin. However, he dismissed
Corticosteroids
CSs with the comment, “cortisone in most instances is
The role of CSs in preventing postoperative mor- probably contraindicated.” However, in the very next
bidity has been addressed in literally hundreds of issue of the same journal, Ross and White56 presented
articles, beginning in the 1950s. Cortisone and hydro- the results of their RCT. Thirty-nine oral surgical pa-
cortisone were first isolated in the 1930s, but it was tients were given hydrocortisone 40 mg 2 times/day
not until the late 1940s that Hench et al46 reported the day before surgery, 4 times/day the day of surgery,
the benefit of the exogenous steroid administration and 2 times/day for 2 days after surgery. Twenty-two
for rheumatoid arthritis. Subsequently, numerous in- patients were given placebo according to the same
vestigations of the efficacy of CSs in specific condi- dose schedule. The investigators noted a statistically
tions and in surgery have been published. By the early significant decrease in edema and trismus in the ex-
1950s, steroids were being used as adjuncts to surgi- perimental group. Pain also was less in the experi-
cal procedures, although concerns were raised as to mental group, but the difference was not statistically
potential problems with wound healing if steroids significant.
were administered. In their review of the then current Nathanson and Seifert57 reported on the effects of
applications of CSs in surgery, Galante et al47 stated: betamethasone in their prospective RCT in 1964. One
“prevention of wound healing . . . is not a problem if hundred ten patients received betamethasone 0.6 mg
these agents are used no more than 5-7 days, in 4 times/day for 4 days beginning immediately postop-
decreasing doses.” eratively, whereas 100 control patients received pla-
In the dental field, Shafer48 studied the effects of cebo. All were examined each day for 5 days by 1 of
cortisone on postextraction wound healing in a rat the investigators. The findings included a significant
model. Thirty-five experimental animals were given decrease in edema in the experimental group, a trend
cortisone 2.5 mg on the day of extraction of an upper to decreased pain in the experimental group, and no
S30 OPERATIVE MANAGEMENT OF THIRD MOLARS

difference in trismus. Because the investigators noted and those who did not return were questioned by
initial edema before the first dose was given, which telephone. Because objective measurements were not
resolved after that dose, their recommendation was performed by the clinicians, there were no statisti-
modified to initiate the drug the day before surgery cally significant differences found in edema, mouth
and to continue 3 days postoperatively. Various sur- opening, or pain. However, there was significantly
gical procedures were performed for these patients. improved sleep in the CS group at days 1 to 4 and
Hooley and Francis58 used the dose recommendations decreased nausea on day 1 in the CS group. Postop-
of Nathanson and Seifert for their prospective RCT of erative visits with treatment (placement of dressings,
476 patients who underwent surgical extraction of an debridement, or antibiotic prescription) occurred in
impacted mandibular M3. The patients served as their 28% of the control group and in 10% of the CS group.
own controls, returning later for the opposite-side Suture removal and irrigation were not considered
surgery by the same surgeon. For the experimental treatment.
side, they received 2 tablets of betamethasone 0.6 mg In a prospective RCT, Buyukkurt et al70 compared
the evening before surgery and then 2 tablets of 0.6 prednisolone 25 mg intramuscular, prednisolone 25
mg 4 times/day the day of surgery and 2 tablets 4 mg plus diclofenac intramuscular, and control (saline
times/day for the next 2 days. Tetracycline cones placebo intramuscular), all given immediately after
were placed into each extraction socket. These inves- M3 surgery. There were 15 patients in each group.
tigators were the first to use cephalometrically posi- Pain intensity was measured on a visual analog scale,
tioned photographs for the objective measurement of and edema was measured objectively in patients on
edema. Their findings showed that the controls had 6 days 2 and 7. These investigators found significantly
times as much edema, 2 times as much trismus, and decreased edema and trismus at days 2 and 7 in the
required 2 times as much pain medication as the prednisolone and prednisolone-diclofenac groups ver-
controls. These investigators commented that they sus the control group. Pain was studied only on the
had used betamethasone for more than 2,000 patients day of surgery and was significantly decreased in the
in the previous 8 years without any systemic compli- prednisolone and prednisolone-diclofenac groups,
cations. with the prednisolone-diclofenac combination being
Over the course of the next 30 years, numerous more effective. These investigators recommended a
articles have appeared comparing various steroids steroid/NSAID combination as more effective than
with placebo, including triamcinolone,59 dexametha- steroid alone. Hyrkäs et al71 previously performed the
sone,60-62 prednisone,63 methylprednisolone,64-66 and reverse comparison, comparing diclofenac alone with
betamethasone.67 the methylprednisolone-diclofenac combination, and
The details of each of these studies were thor- found the combination produced better pain control
oughly discussed in a 1992 review by Gersema and than diclofenac alone.
Baker68 and will not be repeated here. Although al- This potentially synergistic effect of steroid plus
most all of these studies were prospective RCTs, NSAID versus control was investigated in a model of
many also had small subject numbers, inconsistent acute inflammation by Dionne et al.72 In this prospec-
procedures, and subjective observations of results. tive RCT, there were 3 groups: 1) preoperative dexa-
Nevertheless, Gersema and Baker concluded that methasone/postoperative ketorolac; 2) preoperative
“based on these studies, the use of perioperative CSs dexamethasone/postoperative saline placebo; and 3)
appears to be a safe and rational method of decreasing preoperative saline placebo/postoperative saline pla-
postoperative complications of edema, and possibly cebo.
trismus and pain, after the removal of impacted The steroid was administered 4 mg orally at 12
M3s.”68 These investigators recommended a single hours before surgery and 4 mg intravenously 1 hour
preoperative dose of methylprednisolone 125 mg before surgery. The postoperative dose of ketorolac
given intravenously or intramuscularly. 30 mg or saline placebo was given at pain onset,
Most recently, several interesting articles have ap- usually about 2 hours after the procedure. There was
peared that examine previously undiscussed parame- no difference in pain onset in the dexamethasone and
ters or combinations of drugs. Tiwana et al69 prospec- control groups. The pain decrease was significant in
tively compared 60 patients who received preoperative the dexamethasone/ketorolac group only. There was
CSs (dexamethasone 8 mg or methylprednisolone 40 no difference in pain between the steroid/placebo
mg) with 60 similar control patients who did not and placebo/placebo groups. Unfortunately, these in-
receive CSs. No patients in either group received vestigators did not compare the dexamethasone/ke-
antibiotics. All patients in the 2 groups were consid- torolac group with another placebo/ketorolac group.
ered to have higher than average risk for postopera- Thus, whether the combination of steroid and ketoro-
tive sequelae because all had 4 M3s below the occlu- lac is more, less, or equally effective as ketorolac
sal plane. In this study, patients filled in a daily log, alone was not studied.
JOSEPH F. PIECUCH S31

Markiewicz et al73 published their study, “Cortico- of the periodontal tissue of the second molar. J Can Dent Assoc
54:689, 1998
steroids Reduce Postoperative Morbidity After Third 7. Theadom A, Gropley M: Effect of preoperative smoking cessa-
Molar Surgery: A Systematic Review and Meta-Analy- tion on incidence and risk of intraoperative and postoperative
sis,” in 2008. The investigators asked 1 simple ques- complications in adult smokers: A systematic review. Tob
tion: “Among patients undergoing M3 removal, does Contr 15:352, 2006
8. Al-Belasy FA: The relationship of “Shisha” (Water Pipe) smok-
perioperative CS administration, when compared ing to postextraction dry socket. J Oral Maxillofac Surg 62:10,
with similar control, decrease postoperative edema, 2004
trismus, and pain in the early (1-3 days) and late (⬎3 9. Caso A, Hung L, Beirne R: Prevention of alveolar osteitis with
chlorhexidine: A meta-analytic review. J Oral Surg 99:155, 2005
days) postoperative periods?” The study criteria in- 10. Minguez-Serra MP, Salort-Llorca C, Silvestre-Donat FJ: Chlor-
cluded English-language publications, a prospective hexidine in the prevention of dry socket: Effectiveness of
clinical trial, reported descriptive statistics, and, if different dosage forms and regimens. Med Oral Patol Oral Cir
Bucal 14:e445-e449, 2009
reporting pain, a visual analog scale. These investiga- 11. Kirsin I: Pre-emptive analgesia. Anesthesiology 93:1138, 2000
tors initially identified 599 articles on the topic, but 12. Campiglia L, Gonsales G, De Gaudio AR: Pre-emptive analgesia
most did not meet the inclusion criteria, because they for postoperative pain control: A review. Clin Drug Invest
30:15, 2010 (suppl 2)
were retrospective, reviews, case reports, letters to
13. Cliff KS: Efficacy of pre-emptive analgesia for acute postoper-
the editor, or did not involve human subjects. Only 12 ative pain management: A meta analysis. Anesth Analg 100:757,
of these articles yielded extractable data. This illus- 2005
trates the relative absence in the literature of objec- 14. Nayyar MS, Yates C: Bupivacaine as pre-emptive analgesia in
third molar surgery: Randomised controlled trial. Br J Oral
tive data on this important topic. Maxillofac Surg 44:501, 2006
The data reported by Markiewicz et al73 confirmed 15. Pozos-Guillen A, Martinez-Rider R, Aguirre-Banuelos P, et al:
that CSs decrease edema and trismus in the early and Pre-emptive analgesic effect of tramadol after mandibular third
molar extraction: A pilot study. J Oral Maxillofac Surg 65:1315,
late postoperative periods. In terms of pain, even 2007
fewer articles qualified for analysis because most arti- 16. Kaczmarzyk T, Wichlinski J, Stypulkowska J, et al: Preemptive
cles focused on number of analgesic doses and on effect of ketoprofen on postoperative pain following third
molar surgery. A prospective, randomized, double-blinded clin-
analgesic dosage rather on the visual analog scale. ical trial. Int J Oral Maxillofac Surg 39:647, 2010
Consequently, although CSs appeared to decrease 17. Piecuch JF, Arzadon J, Lieblich SE: Prophylactic antibiotics for
pain in the early postoperative period, this finding third molar surgery: A supportive opinion. J Oral Maxillofac
was not statistically significant. Surg 53:53, 1995
18. Zeitler DL: Prophylactic antibiotics for third molar surgery: A
In conclusion, despite a plethora of articles on the dissenting opinion. J Oral Maxillofac Surg 53:61, 1995
various topics covered in this review, there is actually 19. Kay LW: Investigations into the nature of pericoronitis—II. Br J
very little definitive information available. There does Oral Surg 4:52, 1966
20. Curran JB, Kennett S, Young AR: An assessment of the use of
appear to be a consensus that prophylactic antibiotics prophylactic antibiotics in third molar surgery. Int J Oral Surg
and CSs are of benefit in decreasing complications 3:1, 1974
and in improving the postoperative quality of life after 21. Happonen RP, Bäckström AC, Ylipaavalniemi P: Prophylactic
use of phenoxymethylpenicillin and tinidazole in mandibular
M3 surgery. The most interesting area for future re- third molar surgery, a comparative placebo controlled clinical
search is in the area of pre-emptive analgesia, al- trial. Br J Oral Maxillofac Surg 28:12, 1990
though more long-term studies specifically regarding 22. Goldberg MH, Nemarich AN, Marco WP: Complications after
mandibular third molar surgery: A statistical analysis of 500
M3 surgery are needed. consecutive procedures in private practice. J Am Dent Assoc
111:277, 1985
23. Nordenram A, Sydnes G, Odegaard J: Neomycin-bacitracin
cones in impacted third molar sockets. Int J Oral Surg 2:279,
References 1973
1. Chuang SK, Perrott DH, Susarla SM, et al: Age as a risk factor for 24. Mitchell DA: A controlled clinical trial of prophylactic tinida-
third molar surgery complications. J Oral Maxillofac Surg 65: zole for chemoprophylaxis in third molar surgery. Br Dent J
1685, 2007 160:284, 1986
2. Kirk DG, Liston PN, Tong DC, et al: Influence of two different 25. Mitchell DA, Morris TA: Tinidazole or pivampicillin in third
flap designs in incidence of pain, swelling, trismus, and alveolar molar surgery. Int J Oral Maxillofac Surg 16:171, 1987
osteitis in the week following third molar surgery. J Oral Surg 26. Osborn TP, Frederickson G, Small IA, et al: A prospective study
104:e1, 2007 of complications related to mandibular third molar surgery.
3. Sandhu A, Sandhu S, Kaur T: Comparison of two different flap J Oral Maxillofac Surg 43:767, 1985
designs in the surgical removal of bilateral impacted mandibu- 27. Sisk AL, Hammer WB, Shelton DW, et al: Complications follow-
lar third molars. Int J Oral Maxillofac Surg 39:1091, 2010 ing removal of impacted third molars: The role of the experi-
4. Stephens RJ, App GR, Foreman DW: Periodontal evaluation of ence of the surgeon. J Oral Maxillofac Surg 44:855, 1986
two mucoperiosteal flaps used in removing impacted third 28. Capuzzi P, Montebugnoli L, Vaccaro MA: Extraction of im-
molars. J Oral Maxillofac Surg 41:719, 1983 pacted third molars: A longitudinal prospective study. J Oral
5. Quee TA, Gosselin D, Millar EP, et al: Surgical removal of the Surg 7:341, 1994
fully impacted mandibular third molar. The influence of flap 29. Krekmanov L, Hallander HO: Relationship between bacterial
design and alveolar bone height on the periodontal status of contamination and alveolitis after third molar surgery. Int J Oral
the second molar. J Periodontol 56:625, 1985 Surg 9:274, 1980
6. Schofield IDF, Kogon SL, Donner A: Long-term comparison of 30. Hall HD, Bildman BS, Hand CD: Prevention of dry socket with
two surgical flap designs for third molar surgery on the health local application of tetracycline. J Oral Surg 29:35, 1971
S32 OPERATIVE MANAGEMENT OF THIRD MOLARS

31. Swanson AE: A double-blind study on the effectiveness of 52. Stewart CG, Chilton NW: The role of antihistamines and corti-
tetracycline in reducing the incidence of fibrinolytic alveolitis. costeroids in endodontic practice. J Oral Surg 11:433, 1958
J Oral Maxillofac Surg 47:165, 1989 53. Krassner HA: Marked reduction of post-operative sequelae fol-
32. Rood JP, Murgatroyd J: Metronidazole in the prevention of dry lowing oral surgical procedures with prednisone and chlorpro-
socket. Br J Oral Surg 17:62, 1979 phenpyridamine (abstract). Presented at the ADA Annual Meet-
33. Fridrich KL, Olson RA: Alveolar osteitis following surgical re- ing, Miami, FL; November 6, 1957
moval of mandibular third molars. Anesth Prog 37:32, 1990 54. Spilka CJ: The place of corticosteroids and antihistamines in
34. Zuniga JR, Leist JC: Topical tetracycline-induced neuritis: A oral surgery. J Oral Surg 14:1034, 1961
case report. J Oral Maxilllofac Surg 53:196, 1995 55. Hinds EC: Control of postoperative edema. J Oral Surg 16:109,
35. Leist JC, Zuniga JR, Chen N, et al: Experimental topical tetra- 1958
cycline-induced neuritis in the rat. J Oral Maxillofac Surg 53: 56. Ross R, White CP: Evaluation of hydrocortisone in prevention
427, 1995 of postoperative complications after oral surgery: A prelimi-
36. Monaco G, Staffolani C, Gatto MR, et al: Antibiotic therapy in nary report. J Oral Surg 16:220, 1958
impacted third molar surgery. Eur J Oral Sci 107:437, 1999 57. Nathanson NR, Seifert DM: Betamethasone in dentistry. J Oral
37. Ataoğlu H, Oz GY, Candirli C, et al: Routine antibiotic prophy- Surg 18:715, 1964
laxis is not necessary during operations to remove third molars. 58. Hooley JR, Francis FH: Betamethasone in traumatic oral sur-
Br J Oral Maxillofac Surg 46:133, 2008 gery. J Oral Surg 27:398, 1969
38. Monaco G, Tavernese L, Agostini R, et al: Evaluation of antibi- 59. Mead SV, Lynch DF, Mead SG, et al: Triamcinolone given orally
otic prophylaxis in reducing postoperative infection after man- to control postoperative reactions to oral surgery. J Oral Surg
dibular third molar extraction in young patients. J Oral Maxil- 22:484, 1964
lofac Surg 67:467, 2009 60. Ware H, Campbell JC, Taylor RC: Effect of a steroid on post-
39. Poeschl PW, Eckel D, Poeschl E: Postoperative prophylactic operative swelling and trismus. Dent Prog 3:116, 1963
antibiotic treatment in third molar surgery—A necessity? J Oral 61. Messer EJ, Keller JJ: The use of intraoral dexamethasone after
Maxillofac Surg 62:3, 2004 extraction of mandibular third molars. J Oral Surg 40:594, 1975
40. Foy SP, Shugars DA, Phillips C, et al: The impact of intravenous 62. Linenberg WB: The clinical evaluation of dexamethasone in
antibiotics on health-related quality of life outcomes and clini- oral surgery. J Oral Surg 20:6, 1965
cal recovery after third molar surgery. J Oral Maxillofac Surg 63. Caci F, Gluck GM: Double-blind study of prednisolone and
62:15, 2004 papase as inhibitors of complications after oral surgery. J Am
41. Stavropoulos MF, Shugars DA, Phillips C, et al: Impact of
Dent Assoc 93:325, 1976
topical minocycline with third molar surgery on clinical recov-
64. Huffman GG: Use of methylprednisolone sodium succinate to
ery and health-related quality of life outcomes. J Oral Maxillofac
reduce postoperative edema after removal of impacted third
Surg 64:1059, 2006
molars. J Oral Surg 35:198, 1977
42. Halpern LR, Dodson TB: Does prophylactic administration of
65. Sisk AL, Bonnington GJ: Evaluation of methylprednisolone and
systemic antibiotics prevent postoperative inflammatory com-
flurbiprofen for inhibition of the postoperative inflammatory
plications after third molar surgery? J Oral Maxillofac Surg
response. J Oral Surg 60:137, 1985
65:177, 2007
43. Kaczmarzyk T, Wichlinski J, Stypulkowska J, et al: Single-dose 66. Bierne OR, Hollander B: The effect of methylprednisolone on
and multi-dose clindamycin therapy fails to demonstrate effi- pain, trismus, and swelling after removal of third molar. J Oral
cacy in preventing infectious and inflammatory complications Surg 61:134, 1986
in third molar surgery. Int J Oral Maxillofac Surg 36:417, 2007 67. Skjelbred P, Løkken P: Post-operative pain and inflammatory
44. Kaczmarzyk T: Abuse of antibiotic prophylaxis in third molar reaction reduced by injection of a corticosteroid. A controlled
surgeries. J Oral Maxillofac Surg 67:2551, 2009 trial in bilateral oral surgery. Eur J Clin Pharmacol 21:391, 1982
45. Ren YF, Malmstrom HS: Effectiveness of antibiotic prophylaxis 68. Gersema L, Baker K: Use of corticosteroids in oral surgery.
in third molar surgery: A meta-analysis of randomized con- J Oral Maxillofac Surg 50:270, 1992
trolled clinical trials. J Oral Maxillofac Surg 65:1909, 2007 69. Tiwana PS, Foy SP, Shugars DA, et al: The impact of intravenous
46. Hench PS, Kendall EC, Slocumb CH: The effect of a hormone of corticosteroids with third molar surgery in patients at high risk
the adrenal cortex . . . and of pituitary adrenocorticotropic for delayed health-related quality of life and clinical recovery.
hormone on rheumatoid arthritis: A preliminary report. Mayo J Oral Maxillofac Surg 63:55, 2005
Clin Proc 24:181, 1949 70. Buyukkurt MC, Gungormus M, Kaya O: The effect of a single
47. Galante M, Rules M, Forsham P, et al: The use of corticotropin, dose prednisolone with and without diclofenac on pain, tris-
cortisone, and hydrocortisone in general surgery. Surg Clin mus, and swelling after removal of mandibular third molars.
North Am 34:1201, 1954 J Oral Maxillofac Surg 64:1761, 2006
48. Shafer WG: The effect of cortisone on the healing of extraction 71. Hyrkäs T, Ylipaavalniemi P, Oikarinen VJ, et al: A comparison
wounds in the rat. J Dent Res 33:4, 1954 of diclofenac with and without single-dose intravenous steroid
49. Hooley JR, Bradley PB, Haines MP: Plasma cortisol levels fol- to prevent postoperative pain after third molar removal. J Oral
lowing short-term betamethasone therapy for oral surgical pro- Maxillofac Surg 51:634, 1993
cedures, in Transactions of the 4th ICOMS. Copenhagen, 72. Dionne RA, Gordon SM, Rowan J, et al: Dexamethasone sup-
Munksgaard, 1973 presses peripheral prostanoid levels without analgesia in a
50. Williamson LW, Lorson EL, Osbon DB: Hypothalamic-pituitary- clinical model of acute inflammation. J Oral Maxillofac Surg
adrenal suppression after short-term dexamethasone therapy 61:997, 2003
for oral surgical procedures. J Oral Surg 38:20, 1980 73. Markiewicz MR, Brady MF, Ding EL, et al: Corticosteroids
51. Stewart CG: The antihistamines and corticosteroids in the re- reduce postoperative morbidity after third molar surgery: A
duction of sequelae following endodontic surgery. J Oral Surg systematic review and meta-analysis. J Oral Maxillofac Surg
9:216, 1956 66:1881, 2008