| 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
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.  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.  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.
|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 2020 Sep 18];23:709-13. Available from: http://www.ijdr.in/text.asp?2012/23/6/709/111243
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.  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.  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.  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.  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.
- 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.
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 th hourly for 3 days postoperatively.
- 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)
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 t-test 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 anti-inflammatory effect than serratiopeptidase.
|Table 1: Comparison of mean values of facial measurements (in mm) between dexamethasone and serratiopeptidase group|
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[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|
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[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|
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[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.
|Table 4: Comparison of pain in serratiopeptidase and dexamethasone groups|
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| Discussion|| |
The surgical removal of an impacted third molar tooth can result in considerable pain, swelling, and dysfunction. Swelling usually reaches its maximum within 48-72 hours of the surgical procedure.  Minimizing tissue damage can control the amount of postsurgical edema. Some believe that ice applied to the operated area decreases vascularity and thereby diminishes transudation. However, no controlled study has verified this practice. , The vasoactive amines cause vasodilation, thereby increasing blood flow to the inflamed area. The inflammatory process is necessary if healing is to occur but inflammation also causes edema, pain, and trismus. , A meticulous surgical technique can minimize the sequelae of inflammation but will not prevent them. The intensity of the inflammatory process may be reduced by administering corticosteroids. 
Glucocorticoids are a group of steroids that possess anti-inflammatory properties. The primary glucocorticoid secreted by the zona fasciculata of the adrenal cortex is cortisol (hydrocortisone).  Normally, the body produces approximately 15-30 mg of hydrocortisone per day. , The corticosteroids affects the movement, activation and function of leukocytes and prevents prostaglandin synthesis by inhibiting the arachidonic acid cascade. 
Enzymes are extremely potent substances and the possibility of their therapeutic application in inflammation is attractive. Enzymes are derived from various sources, including bacteria (e.g., streptokinase and streptodornase). Chymotrypsin is a proteolytic enzyme obtained from the bovine pancreas and is used for management of edema.
Swelling involves a three-dimensional volumetric change at the tissue and cellular level. No technique has been proved to be superior or more accurate than any other in analyzing swelling. The desire to include large number of patients, and the practicability of this low-cost and reliable technique, made linear measurements a reasonable choice in this study. The swelling was also measured in terms of cheek girth, using calibrated slide calipers.
In the studies conducted by Elhag et al., Weber and Griffin, and Beirne and Hollander for establishing the anti-inflammatory effects of dexamethasone, the dexamethasone group had mean pain and swelling scores significantly lower than that of the controls. ,,
A prospective study was conducted by Al-Khateeb and Nusair to evaluate the usefulness of serratiopeptidase for reduction of postoperative swelling, pain, and trismus after third molar surgery. They concluded that significant reduction in swelling could be achieved with use of serratiopeptidase.  Chopra et al. conducted a randomized, double-blind, placebo-controlled study to compare the efficacies and safety of acetaminophen, serratiopeptidase, ibuprofen, and betamethasone. They found that acetaminophen provides statistically significant benefit when compared with placebo for pain relief after third molar surgery. Compared with a nonsteroidal anti-inflammatory drug (ibuprofen), acetaminophen did not prove to be better in terms of reduction of pain scores or rescue medication requirement. The authors also reported that corticosteroids produce analgesic action, albeit with a delay.
In this study we found that in the dexamethasone group the pain was moderate on the 1 st postoperative day but was graded as mild on the 3 rd , 5 th , and 7 th days. This observation is consistent with the findings of Chopra et al. There was statistically significant reduction of cheek girth on the 1 st , 3 rd , and 5 th postoperative days in patients taking dexamethasone. In this study we noticed that both dexamethasone and serratiopeptidase were effective in minimizing the postoperative inflammation. However, there was a definite difference between dexamethasone and serratiopeptidase, with dexamethasone being superior to serratiopeptidase in reducing inflammation.
Buyukkurt found that a single dose prednisolone, with and without diclofenac, was effective for the treatment of postoperative pain, trismus, and swelling after dental surgical procedures.  Sisk et al. evaluated methylprednisolone and flurbiprofen for the inhibition of the postoperative inflammatory response and found that a combination of these two drugs was necessary to control postoperative pain effectively. However, in contrast to the finding of Buyukkurt,  both drugs appeared to be ineffective in controlling postoperative trismus. 
In the serratiopeptidase group in this study, severe pain was recorded on first day but this reduced subsequently. Thus, the combination of dexamethasone and paracetamol was more effective for pain control on the first day than the combination of serratiopeptidase and paracetamol. In comparison with serratiopeptidase, dexamethasone appears to be more potent in controlling postoperative swelling and pain. With regard to trismus, our study showed similar results as the studies by Sisk and Bonnington  and Al-Khateeb and Nusair:  both dexamethasone and serratiopeptidase do not relieve trismus.
| Conclusion|| |
Two different drugs were compared for efficacy on postoperative swelling, pain, and trismus. In this study serratiopeptidase and dexamethasone had equal and minimal effect on trismus. Dexamethasone was better than serratiopeptidase for the control of pain and swelling. Serratiopeptidase can be used as an alternative drug to control inflammation in cases where corticosteroids are contraindicated.
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Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road, Maduravoyal, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]