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Journal of Critical Reviews

ISSN-2394-5125 Vol 7, Issue 7, 2020

A COMPARATIVE STUDY OF SODIUM WITH PIROXICAM IN PATIENTS UNDERGOING SURGICAL REMOVAL OF THIRD MOLAR

Dr. Nilesh Mishra1, Dr. Ashish Mahamuni2

1Professor, Head & Corresponding Author, Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Krishna Institute of Medical Sciences Deemed To Be University, Karad. Dist-Satara (India) 2Post Graduate Student, Faculty of Dental Sciences, Krishna Institute of Medical Sciences Deemed To Be University, Karad. Dist- Satara (India)

Corresponding Author Dr. Nilesh Mishra Email- [email protected]

Received: 20.02.2020 Revised: 14.03.2020 Accepted: 12.04.2020

Abstract The current study was aimed at assessing the efficacy of Piroxicam verses diclofenac sodium as an after removal of third molars when given post operatively. The study was a comparative evaluation between two drugs. Methods - The current study was done in Department of Oral Maxillofacial Surgery, after the due approval of the Institutional Ethical Committee. A prospectiverandomized study conducted with 30 patients that required removal of mesio angularly impacted mandibular third molar. The systematical statistical analysis was performed after the data collection was done. Results- Pain intensity at the postoperative 15 mints, 30 mints, 45 mints,60mints, 2nd, 3rd, 7th day postoperative was less in Piroxicam group than Diclofenac and there was significant difference seen statistically (p<0.001).Swelling and Trismus were not statistically significant, however there were significant reduction in Swelling and Trismus on 2nd day. Conclusion-The ease of use and reduction in dosage of the than the conventionally used NSAIDs and increased patient compliance makes Piroxicam an advantageous drug used in minor dental surgeries.

Keywords-Anti-Inflammatory, Piroxicam, Diclofenac Sodium, Mandibular Third Molar

© 2020 by Advance Scientific Research. This is an open-access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/) DOI: http://dx.doi.org/10.31838/jcr.07.07.122

INTRODUCTION is for the most part liable for the union of . Its Careful expulsion of affected mandibular third molar is the most essential capacity is to intercede the reactions to neurotic usually performed strategy in Oral , Maxillofacial Surgical procedures, for example, aggravation, torment and fever. practice [1]. Because of unavoidable post-surgical complications, Diclofenac potassium is a NSAID that is accessible in two it is often difficult for a patient to decide to remove a third structures. One is a quick discharge oral potassium salt as molar[2]. Pain experienced by the patient after surgical removal while the other is postponed discharge sodium salt tablet. of third molar is typically moderate to severe which is lasting for Piroxicam is another non-steroidal pain relieving and mitigating more than 24 hours[3]. Patients require torment the board specialist random artificially to other accessible medications. As postoperatively as torment from lower third molar extraction a pain relieving, Piroxicam is progressively powerful (weight-for arrives at its most extreme power not long after the finish of the weight) than , , , or medical procedure [4]. Other than torment, expanding and in restraining Phenylquinone-incited squirming. trismus related with aggravation, there are further unfortunate In fundamental investigations, Piroxicam 20 mg day by day ramifications for these patients who experience careful caused less fecal blood misfortune than ibuprofen 3.8 g every day evacuation of third molars [5]. Patients related factor, tooth in people. Piroxicam, in the same way as other non-steroidal related factor and operative factors are affecting postoperative calming drugs, represses the optional period of platelet morbidity. In youthful patient encompassing bone is relative accumulation initiated by adenosine diphosphate (ADP) and delicate and stronger contrasted with more seasoned patient in collagen-prompted conglomeration. In vitro and in vivo, which bone is harder, requiring increasingly bone expulsion Piroxicam is an inhibitor of union, being a bringing about progressively postoperative torment, growing particular reversible inhibitor of the venture of and trismus[6]. In general, treatment for pain, swelling arachidonic corrosive digestion. Piroxicam is promptly retained andtrismus after lower third molar surgery may include from the oral or rectal courses and arrives at consistent state application of external cold dressing, modulating the closure after around 7 days. The purpose of study was to comparatively technique, varying the dressing agents, open versus closed assess the efficacy of a Piroxicam and Diclofenac sodium in dressing, modulating extent of surgical trauma, skill of surgeon, management of post-operative pain after lower third molar surgical technique, modifying the flap design, pharmacological surgery. methods, anti-inflammatory drugs, analgesics, antibacterial mouthwashes and steroidal therapy[1]. Non-steroidal Anti- MATERIALS AND METHODS Inflammatory Drugs are effective in managing pain associated The present study was undertaken in Department of Oral with oral surgery. They have more of a therapeutic effect and act Maxillofacial Surgery, Faculty of Dental Sciences KIMSDU, Karad, by inhibition of Cyclooxygenase (COX) that in turn inhibits after the due approval of Institutional Ethics Committee. A prostaglandin production. The two isoforms of COX are known as prospectiverandomized study conducted in 30 patients that COX-1 , COX-2. COX-1 is a constitutive structure that is available required removal of mesioangularly impacted mandibular third in practically all tissues and is answerable for the physiological molar. Both male and female patients reporting to the elements of prostanoids, bringing about gastric mucosal Department requiring impacted mandibular third molar assurance and vascular homeostasis. COX-2 is found in a set extraction with Class I B were considered according to Pell and number of tissues, for example, kidney, prostate and mind which Gregory classification.

Journal of critical reviews 669

A COMPARATIVE STUDY OF DICLOFENAC SODIUM WITH PIROXICAM IN PATIENTS UNDERGOING SURGICAL REMOVAL OF THIRD MOLAR

INCLUSION CRITERIA swelling % on 2nd day among 2 groups (SG and CG) with 1. Patients requiring extraction of impacted third molars p=0.197 & Z= -1.291 There is no significant difference among 2. Patients in the age group between 18 to 35 years swelling % on 3rd day among 2 groups (SG and CG) with p=0.064 3. Patients having class B and class 1 impacted teeth (Pell and & Z= -1.852 There is statistically significant difference among Gregory) and swelling % on 7th day among 2 groups (SG and CG) with p<0.001 4. Those surgeries taking more than 15 minutes and less than & Z= -3.991 45 minutes 5. Patients willing to participate. Trismus Descriptive statistics were expressed as Mean ± SD for Study and EXCLUSION CRITERIA Control Group in trismus (n=30). The change in Mean scores of 1. Medically compromised patients eg. Diabetes, Renal Trismus over a 7 days period was analyzed using repeated diseases, diseases etc. measures ANOVA test followed by Bonferroni post hoc test. 2. Known sensitivity to NSAIDs and Local Anesthetic agents. A. Study Group The minimum trismus score in the Study METHOD OF COLLECTION OF DATA Group (n=30) at baseline was 30.400 while maximum was All patients were informed about the nature of study and consent 52.900 with Mean 42.903 ±5.680 The minimum trismus was obtained. Patients were subjected to the same standardized score in the Study Group (n=30) at 30 min was 25.900 surgical protocol by the same surgeon. Only the patients having while maximum was 46.300 with Mean 35.603 ±5.448 mesioangular impacted third molars with class I B classification The minimum trismus score in the Study Group (n=30) at 1 according to Pell and Gregory’s classification were selected for hour was 25.900 while maximum was 39.300 with Mean the study. The surgery that took more than 15 mints and less 33.020 ±4.788 The minimum trismus score in the Study than 45 mints was considered for the study to equalize the Group (n=30) at day 2 was 23.400 while maximum was difficulty of the surgical procedure. 44.200 with Mean 33.423 ±5.196 The minimum trismus Patient’s sides were divided in two groups. Right side was score in the Study Group (n=30) at day 3 was 22.100 while considered as the Study Group and left side was considered as maximum was 45.300 with Mean 34.306 ±5.580 The the Control Group. After extraction, Piroxicam was used in Study minimum trismus score in the Study Group (n=30) at day 7 Group whereas Diclofenac sodium was used in Control Group. was 29.100 while maximum was 51.600 with Mean 40.696 ±5.492 Group A (Study Group) B. Control Group The minimum trismusscore in the Study The patients in this group received Tab. Piroxicam (Dolonex DT, Group (n=30) at baseline was 30.400 while maximum was Ltd. Mumbai, India). The tablet used was of 20 mg twice a 52.900 with Mean 42.903 ±5.680 The minimum day for three days. Tab. Piroxicam was given to the patient after trismusscore in the Study Group (n=30) at 30 min was the onset of the pain. 26.000 while maximum was 45.500 with Mean 35.216 ±5.230 The minimum trismus score in the Study Group Group B (Control Group) (n=30) at 1 hour was 26.000 while maximum was 40.000 In this group patients received Tab. Diclofenac sodium (Voveran- with Mean 32.020 ±4.449 The minimum trismusscore in D, Novartis Pharma, Mumbai, India). The tablet used was 50 mg the Study Group (n=30) at day 2 was 20.400 while thrice a day for three days and the tablet was given after the maximum was 42.400 with Mean 32.256 ±5.690The onset of the pain. minimum trismusscore in the Study Group (n=30) at day 3 Observations and Results was 20.400 while maximum was 42.400 with Mean 33.451 ±5.580.The minimum trismusscore in the Study Group Pain (n=30) at day 7 was 28.600 while maximum was 50.500 Study Group At 15 mints after operative procedure pain score with Mean 40.250 ±5.565. was minimum 3 and maximum 7 with mean of 5.30. After 30 mints pain score was minimum 1 and maximum 4 with mean of DISCUSSION 2.60. After 45 mints pain score was maximum 1 with mean of Careful evacuation of affected mandibular third molars is one of 0.30. After 1 hour of operative procedure no pain was present in the most widely recognized techniques did in oral and any patient. On day 2 of postop pain score was minimum 2 cases maxillofacial medical procedure.Most third molar medical and maximum 6 with mean of 3.47. On day 3 postop pain score procedures are performed without difficulties. Be that as it may, was minimum 1 and maximum 5 with mean of 2.57. On 7th such technique can prompt intricacies including tireless torment, postop day pain was present in maximum 3 cases with mean of growing and trismus[7]. Pain can be produced peripherally, as a 1.03. result of tissue damage and (inflammatory pain), central nervous system damage (neuropathic pain) or due to Control Group alterations in the normal function of nervous system (functional At 15 mints after operative procedure pain score was minimum 3 pain) [8]. Excessive touchiness to agony might be a typical and maximum 6 with mean of 5.30. After 30 mints pain score postoperative indication in surgeries. The vibe of torment at the was minimum 1 and maximum 6 with mean of 3.10.After 45 careful site might be expanded and continue for longer periods mints pain score was maximum 3 with mean of 1.03. After 1 much after the expulsion harmful upgrade, portraying the hour of operative procedure pain score was maximum 1 with procedure of hyperesthesia. Such an expansion in affectability mean of 0.10. On day 2 of postop pain score was minimum 4 and may likewise bring about torment at the encompassing region of maximum 7 with mean of 5.47. On day 3 postop pain score was the careful site which portrays the idea of allodynia[9]. There are minimum 3 and maximum 7 with mean of 4.97. On 7th postop two instruments that are engaged with difficult excessive day pain score was minimum 1 and maximum 4 with mean of touchiness: Peripheral sharpening, (limit decrease and increment 2.07. in the responsiveness of the fringe afferent nociceptive terminals) and Central refinement (fringe sores trigger Swelling compound change-over in the descendent agony control The percentage of swelling were compared by Friedman’s test framework) [9]. Post-usable agony from the extraction of (Non-parametric Test for ANOVA). While two groups – affected molar may make genuine distress the patient[10]. This is intergroup comparison was done by Mann Whitney ‘U’ test (Non arranged as agony being of short to direct term, arriving at its parametric Test).There is no significant difference among greatest power at the primary postoperative twelve hours[11].

Journal of critical reviews 670

A COMPARATIVE STUDY OF DICLOFENAC SODIUM WITH PIROXICAM IN PATIENTS UNDERGOING SURGICAL REMOVAL OF THIRD MOLAR

The resulting pain from this kind of surgery is used as one of the equally effective for postoperative pain, trismus, and main parameters for assessment of pharmacological efficacy of swelling management in lower third molar removal. Oral different analgesia methods. surgery, oral medicine, oral pathology and oral radiology, 114(1), 27-34. Pain 6. Ahmed, S. S., ElSharrawy, E. A., & Hamed, T. A. (2014). In Study Group pain score was maximum on 2ndand 3rdday . Clinical evaluation of Cox-2 inhibitor for management of There was no marked difference in the pain intensities of second post operative complications after odontectomy of and the third days. The pain minimizes or nearly subsides at the impacted lower third molar. J. Am. Sci., 10(11). seventh post-operativeday. In the Control Group Pain intensity 7. Deliverska, E. G., & Petkova, M. (2016). Complications after was comparatively greater in Study Group compared to Control extraction of impacted third molars-literature review. Group with mean of 5 according to VAS on day 2 and 2 on day 7 Journal of IMAB–Annual Proceeding Scientific Papers, post-operative period. 22(3), 1202-1211. 8. Borsook, D. (2012). Neurological diseases and pain. Brain, Swelling 135(2), 320-344. In Study Group the swelling observed was maximum in the post- 9. Kelly, D. J., Ahmad, M., & Brull, S. J. (2001). Preemptive operative period with respect to preoperative dimensions in the analgesia I: physiological pathways and pharmacological sample size of 30 was maximum on the day 2 and day 3. Swelling modalities. Canadian journal of anaesthesia, 48(10), 1000- gradually declined after the day 3. The swelling was present on 1010. the seventh day 7, but was minimum compared to that in the 10. Chaparro-Avendaño, A. V., Pérez-García, S., Valmaseda- postoperative dimensions. In Control group the swelling Castellón, E., Berini-Aytés, L., & Gay-Escoda, C. (2005). observed was maximum in the immediate post-operative period Morbidity of third molar extraction in patients between 12 compared to the preoperative dimensions. Swelling was nearly and 18 years of age. Medicina oral, patologia oral y cirugia equal on the day 2 and the day 3 post-operative that gradually bucal, 10(5), 422-431. declined till the day 7. The swelling on the seventh day was 11. De Menezes SA, Cury PR. Efficacy of versus minimum compared to that of the preoperative dimensions. in the control of pain, swelling and trismus following extraction of impacted lower third molar. Int J Mouth Opening Oral MaxillofacSurg 2010;39(6):580-4. In study group the mouth opening of the patients reduced on the immediate day 2 of surgery as compared to the preoperative dimensions. The mouth opening began to increase on the post- operative day 3 and subsequently increased in the post-operative day 7. The mouth opening was comparable with the preoperative dimensions. In control group the mean values of the mouth opening tend to decrease gradually as compared to the preoperative dimensions from the post-operative period with the least mouth opening being in the day 2.The mouth opening on seventh day is maximum with respect to other postoperative values in the parameter.

CONCLUSION The ease of use and reduction in dosage of the analgesics than the conventionally used NSAIDs and increased patient compliance makes Piroxicam an advantageous drug used in minor dental surgeries.

Source of Funding-KIMSDUkarad

Conflict of Interest-Nil

REFERENCES 1. Mohammad, S., Singh, V., Wadhwani, P., Tayade, H. P., & Rathod, O. K. (2012). Sublingual piroxicam in the management of postoperative pain after surgical removal of impacted mandibular third molar. Indian Journal of Dental Research, 23(6), 839. 2. Balihallimath, L. J., & Shruti, S. P. Sublingual piroxicam for management of postoperative pain, trismus and swelling after extraction of lower third molars: an overview. 3. Nørholt, S. E. (1998). Treatment of acute pain following removal of mandibular third molars: use of the dental pain model in pharmacological research and development of a comparable animal model. International journal of oral and maxillofacial surgery, 27, 1-41. 4. McGrath, C., Comfort, M. B., Lo, E. C. M., & Luo, Y. (2003). Changes in life quality following third molar surgery–the immediate postoperative period. British dental journal, 194(5), 265-268. 5. Trindade, P. A., Giglio, F. P., Colombini-Ishikiriama, B. L., Calvo, A. M., Modena, K. C. S., Ribeiro, D. A., ... & Santos, C. F. (2012). Sublingual and sublingual piroxicam are

Journal of critical reviews 671