|Year : 2015 | Volume
| Issue : 1 | Page : 31-34
Preventing postoperative swelling after periodontal surgery
Jaisika Rajpal1, Aakash Arora2, Ruchika Prasad3, Madhav Mukund Gupta4
1 Department of Periodontology, Subharti Dental College, Meerut, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Subharti Dental College, Meerut, Uttar Pradesh, India
3 Department of Oral Medicine, Sardar Patel Dental College, Lucknow, Uttar Pradesh, India
4 Department of Periodontology, Faculty of Dental Sciences, CSMMU, Lucknow, Uttar Pradesh, India
|Date of Web Publication||7-Jul-2015|
45/A, Aashirwad Bhawan, Beside Maittri Niwas Guest House, Krishna Nagar, Kanpur Road, Lucknow - 226 023, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Postoperative swelling following different surgical strategies is an area of great interest. The main part of the literature on the topic deals with swelling after periodontal surgery. In this review, we take into account different surgical strategies used including various flaps, no traumatic osteotomy, and primary or secondary closure. The use of pharmacological therapy and application of an ice pack is critical in the postoperative period and has always provided positive results. However, even if it is difficult to come to definite conclusions, due to the variability of the design of studies analyzed, the postoperative discomfort identified with edema, pain and trismus following wisdom tooth removal is influenced by various factors such as the difficulty of the surgical procedure involved, age and gender of the patient, and experience of the surgeon. The pharmacological therapy when performed with corticosteroids seems to improve control of the postoperative swelling related to this kind of surgeries.
Keywords: Antibiotics, corticosteroid, cryotherapy, postsurgery swelling
|How to cite this article:|
Rajpal J, Arora A, Prasad R, Gupta MM. Preventing postoperative swelling after periodontal surgery. J Oral Res Rev 2015;7:31-4
|How to cite this URL:|
Rajpal J, Arora A, Prasad R, Gupta MM. Preventing postoperative swelling after periodontal surgery. J Oral Res Rev [serial online] 2015 [cited 2019 Jan 23];7:31-4. Available from: http://www.jorr.org/text.asp?2015/7/1/31/160193
| Introduction|| |
A surgical trauma in the oral cavity always causes tissue injury characterized by hyperemia, vasodilatation, increased capillary permeability with liquid accumulation in the interstitial space and granulocyte and monocyte migration, due to the increased osmotic pressure in capillaries (Starling law).  Edema is the expression of exudates or transudation, and in surgery, probably both the events occur. Transudation, in fact, is secondary to blood flow slowing (i.e., hyperemia, vasodilatation, stenosis, etc.), whereas a superimposed infection is responsible for exudates. 
Extension of the incision, as well as tissue manipulation and length of surgery, could affect the entity of swelling. According to previously published data, postoperative swelling and pain are significantly lower following a smaller incision. ,
When periodontal surgery is performed, postsurgery is characterized by a limitation in the mouth opening, pain, reduced masticatory capability and swelling of variable degree. The latter represents a serious issue as it affects the ability of the patient to interrelate and to return to the routine working life, especially during the first 3 days following oral surgery. ,,,,, The postoperative period of a patient is hardly predictable. According to Akadiri et al. gender, weight and body surface affect postoperative swelling. However, it is difficult before surgery to predict the entity of edema to occur as this will be the result of several components. In fact, different issues deserve consideration when evaluating the difficulties of one surgical approach versus another, as suggested by Akadiri et al.
Much attention is given to radiography, dental morphology, type of defect, type of flap, duration of surgery, but age of the patient, as well as experience of the surgeon, should also be taken into account. Postoperative events (pain, trismus, swelling, mouth opening limitation) are usually treated with pharmacological and/or surgical and/or various strategy interventions. To this purpose, different surgeons treat postoperative swelling in the preoperative period or in the postoperative period or in both the periods or, in some cases, even during surgery. The objective of this article is to investigate the most recent literature on methods utilized to control and reduce swelling that occurs after periodontal surgery.
Postoperative discomfort may be considered a used term that can nevertheless cause misunderstandings due to its ambiguity. This topic is very much debated in the current international literature. This review will focus on the technical and pharmacological parameters influencing postopertative pain, swelling and trismus.
| Pharmacologic Strategies|| |
Antibiotic therapy to treat established infection or as prophylactic strategy to prevent distance site infection or to control postoperative discomfort in periodontal surgery is today a broadly accepted indication with documented efficacy.
However, the great variability in the pharmacologic administration related to parameters like time and way of administration, posology and chemical structure seems to influence the effectiveness of the postoperative discomfort. Surgeons use antibiotic prophylaxis, even if some controversies exist in this regard. In a study reported by Halpern et al., reduction of both alveolar osteitis and inflammation was observed in patients treated with penicillin (15,000 UI/kg bw, IV) or clindamycin (600 mg in subjects allergic to penicillin), 1 h before surgery versus placebo-treated control patients. Administration of amoxicillin (2 g orally), 1 h before surgery, did not result in any improvement in the postoperative period versus untreated controls.
According to Martin et al., parenteral antibiotic prophylaxis should be applied only in the case of osteotomy, whereas the surgeons are suggested to limit the use of second- and third-generation antibiotics in periodontal surgeries.
In patients treated with amoxicillin/clavulanic acid (1 g, twice a day, for 5 days before surgery), no significant differences were observed versus patients treated with the same drug for 5 days following surgery.
The effectiveness of antibiotic prophylaxis seems to be highly recommended for patients who present with a high risk of infection or when traumatic surgical procedures have been performed. ,,
Antibiotics are largely used in the postoperative period. They can be applied topically or administered systematically, but the efficacy of antibiotic treatment in the preoperative period is also highlighted. According to some authors, to obtain results with the antibiotic treatment, they must be administered preoperatively to act when the bacterial infection starts. 
In contrast, no significant difference as regards to pain, swelling and trismus was reported in a study which compared no antibiotic therapy with administration of clindamycin 300 mg, 3 times a day, for 5 days, and amoxicillin/clavulanic acid 1 g, 2 times a day, for 5 days.
Sekhar et al., using metronidazole, 1 g, 1 h before surgery, and 400 mg every 8 h for 5 days after surgery, reported that antibiotic treatment is not efficacious either in the pre-or postoperative period.
According to the literature review, the use of the antibiotics before surgery could be considered a predictable procedure to avoid and control the possible infection related to the surgery. If infection and inflammation are present in the surgical area, an antibiotic therapy seems to give a better clinical compliance of the tissues undergoing surgery. The antibiotic administration before, during and after surgery seems to be a better therapeutic choice for controlling the infection arising in the postoperative period.
Most surgeons utilize corticosteroids based on the recognized efficacy to control surgery outcomes and to yield a comfortable postsurgery period. However, there are no definite protocols relative to different molecules or regimens, time and route of administration.
Corticosteroids are known to reduce inflammation, fluid transudation and edema.  They represent the most efficacious anti-inflammatory agents and to this purpose can be used in several different conditions.  However, important adverse effects limit their use in all patients. The mechanism of action of corticosteroids has been largely reviewed by several authors, , and those that are preferentially utilized in dentoalveolar surgery include dexamethasone (administered orally), dexamethasone sodium phosphate (IV or IM), dexamethasone acetate (IM), methylprednisolone (orally), methylprednisolone acetate and methylprednisolone sodium succinate (IV or IM). In the past, betamethasone has been used as well. ,
Milles and Desjardins  obtained good results with the administration of methylprednisolone (16 mg, orally, 12 h before; and 20 mg, IV, immediately before surgery) against placebo administration as one oral tablet 12 h preoperatively. They also suggested continuing administration of the latter for at least 3 days following surgery.
Similarly, Bystedt and Nordenram suggested avoiding very high dosages and a maximum 5-day therapy. In contrast, Helhag et al. suggested that 10 mg dexamethasone, 2 times a day, reduces plasma cortisol levels.
Good results were also obtained with 32 mg methylprednisolone and 400 mg ibuprofen administered 12 h before and 12 h after surgery respectively.
The most frequently used long acting steroid is dexamethasone that is about 25-30 times more potent than cortisol. It is available in oral, parenteral and topical formulations and is largely used in oral surgery pre-or only postsurgery due to its high efficacy and long half-life. Postoperative edema can also be controlled with dexamethasone administered in the submucosa.
Elhag et al.  reported that administration of 10 mg dexamethasone IM, 1 h before surgery and 10-18 h later together with antibiotic therapy (400 mg oral metronidazole, administered pre-and post-surgically), significantly reduces swelling when compared to only postoperative treatment, without corticosteroids.
The investigated studies showed how the effectiveness of the corticosteroid administration before surgery could not be considered as a predictable therapy in order to control the postoperative swelling and edema of the surgical area. However, corticosteroid administration during the surgeries or in the postoperative period seems to give a great benefit for reducing the swelling and postoperative edema. 
Different surgical strategies have been reported in the literature to reduce the postoperative discomfort after the periodontal surgeries. They can be used either separately or in association with pre-or postoperative strategies. Different kinds of flaps have been used specifically to assess whether a marginal flap could control postoperative swelling better than a para-marginal one.
No significant difference in the entity of swelling was observed after using the two kinds of flaps. However, there were no significant differences between the marginal and paramarginal flaps in terms of swelling.
In other studies, attention has been focused on the effect of primary or secondary healing on swelling. According to several authors, tight closure favors edema formation by creating a unidirectional valve that allows fragments of food to reach the cavity, but not to leave it easily. This can be the origin of local infection, inflammation, edema and potential alveolar osteitis and pain for difficult draining.
According to other authors, different factors such as edema, pain and trismus that follow extraction of impacted third molars can be related to suture technique and to surgery length, and the use of a draining tube can be helpful in reducing or preventing postoperative swelling.
Different surgical procedures have also been related to postoperative swelling. Osteotomy through piezosurgery has given positive results on tumefaction compared with traditional techniques. 
Therapeutic effects of ice applied on a surgery wound are due to changes of hematic flow and consequent vasoconstriction and reduced metabolism.  In surgery and orthopedics, in fact, the main function of ice on the treated area is to produce vasoconstriction and to control bleeding, resulting in reduced metabolism and control of bacterial growth. ,
It has to be taken into account that ice applied on an area such as the jaw angle produces rapid chilling in the cutaneous layer, but the effect is much lesser and occurs much later in deep tissues such as the bone.
The application of ice does not have to be too long as this may be responsible for tissue death due to prolonged vasoconstriction, ischemia, and capillary thrombosis. The first physiological response of tissues to cryotherapy is the reduction of local temperature that causes reduced cellular metabolism. In this way, cells consume less oxygen and resist longer to ischemia. 
In contrast, van der Westhuijzen et al. state that there is no scientific evidence to support the use of an icepack in periodontal surgery and report that a slight, but not significant, difference in swelling was observed in patients in whom ice was applied continuously for 24 h after dentoalveolar surgery as compared to untreated controls. Similar lack of efficacy has also been reported by other authors.
It is interesting to note that low laser dosage (4J cm 2 ), applied soon after surgery, produces a good control of swelling, especially in patients treated with 4 mg dexamethasone IM.
| Discussion|| |
A large body of investigations has been performed on the control of postoperative edema in dental surgery. Postsurgical facial swelling affects the daily life of the patient. Many authors have advocated the use of corticosteroids to limit postoperative edema due to their suppressive action on transudation,, but few have made definitive recommendations supported by randomized clinical trials.
In most of the studies, the use of corticosteroid drugs has been analyzed. Specifically, corticosteroids include compounds with short, intermediate and long duration of action. In the last years, compounds that are more frequently used are dexamethasone and methylprednisolone that are 4-5 times more efficacious than the natural compound cortisol and can be administered orally or IM or IV. Dexamethasone has a longer duration of action and is more efficacious.
All the studies reported in the literature have utilized different molecules, dosages, routes and time of administration. While using corticosteroids in the postoperative period, it is preferable to administer drugs 1 h before surgery if they are administered parenterally, or 2-4 h in advance, if taken orally.
In some cases, a single preoperative administration has been adopted whereas in others, the treatment has been administered before and after surgery or associated with antibiotics after surgery.
In all these studies, positive results were obtained, confirming the general anti-inflammatory properties of corticosteroids irrespective of a specific compound, dosage, and timing.
The immediate postoperative endoalveolar or submucosal administration of dexamethasone produces a beneficial effect in preventing inflammatory sequelae of periodontal surgery. In particular, the topical application of 4 mg dexamethasone gave rise to less edema and trismus, and lower patient pain perception after both 2 and 7 days of the surgical removal.
The use of antibiotic therapy has been analyzed in several studies. Either topical or systemic application has been used and again results obtained in all the studies are not comparable due to the different molecules, routes of administration and timing used. As mentioned earlier, corticosteroids have been used sometimes in association with antibiotic therapy.
Covomicyn D and minocyclin have been administered topically, endoalveolarly. Positive results on postoperative swelling were obtained following treatment with 15,000 UI/kg penicillin administered IV, 1 h before surgery. In contrast, clindamycin at a dose of 300 mg orally, 3 times a day for 5 days postsurgery, and amoxicillin/clavulanic acid at a dose of 1 g orally, 2 times a day for 6 days did not produce positive effects.
Similarly, metronidazole given 1 g presurgery and 400 mg 3 times a day for 5 days postsurgery, as reported by Sekhar et al., and amoxicillin/clavulanic acid at a dose of 1 g, 2 times a day for 5 days, either before or after surgery, failed to cause effects on postoperative swelling.
Finally, the importance of wound draining and suture, the specific flaps used, second intention healing or the application a loose closure have to be taken into account. In addition, some studies support the effect of the osteotomy with piezosurgery on postoperative swelling. More controversial are data concerning the effect of cryotherapy on swelling. In fact, while according to some authors, the use of ice pack after surgery is efficacious, it does not affect postoperative edema as reported in other studies.
| Conclusions|| |
Postoperative swelling is a common event after periodontal surgery of and may affect, only for a few days, the social and working life of the patient. Clinicians should manage the postoperative discomfort after the surgery as well as they can.
While most surgeons adopt antibiotic therapy in the postoperative period, more questionable is the use of antibiotics administered presurgery. Again, in this case, a great discrepancy among different studies exists due to the variety of molecules, timing and routes of administration used.
The intraoperative strategies have been less analyzed. Surgical flaps do not seem to have a major role on edema and piezosurgery has not been applied extensively enough to support a positive effect on the control of edema.
In the postoperative period, the use of ice pack is largely recognized to provide good results, and it helps the patient to cooperate with pharmacological treatments and/or intraoperative strategies in the prevention of edema. All pharmacological therapies used postsurgery are valid although they differ in the compounds used and their ways of administration.
This review clearly investigated all the ways and treatment used for controlling the symptoms and signs related to the periodontal surgery. There is growing recognition that the impact of oral conditions on quality of life is an important outcome that can be quite useful in making treatment decisions. All the data developed by this review could be useful for the clinicians in order to show all the surgical and pharmacologic parameters that may influence the postoperative discomfort.
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