Can Topical Agents (Arnica and
Mucopolysaccharide Polysulfate)
Reduce Postoperative Pain, Edema and
Trismus Following Mandibular Third
Molar Surgery?
Background: Postoperative supplemental maintenance following mandibular third molar surgery remains an area of interest.
Purpose: Topical agents can modulate inflammatory processes. The aim of the present study was to determine if topical application of arnica or mucopolysaccharide polysulfate (MPSP) reduces pain, trismus, and edema following the removal of impacted mandibular third molars.
Materials and Methods: A single center randomized controlled clinical trial was conducted. The patients were randomized into three groups: the control group (standard therapy [ST]: antibiotic + nonsteroidal anti-inflammatory drugs twice a day), the arnica group (arnica + ST), and the MPSP group (MPSP + ST). The patients’ pain, trismus, and edema values were measured preoperatively and on postoperative days 1, 3, 5, and 10. Sex, age, and operation time were also included. Analyses included descriptive statistics, analysis of variance, post hoc tests, and determinations of intraclass correlation coefficients. Statistical significance was set at P < .05.
Results: Sixty patients with a mean age of 26.98 ! 10.88 years were included in the study; 55% were females and 45% were males. The mean operation time was 23.8 ! 3.27 minutes. According to the visual analogue scale scores (in centimeter units), the arnica and MPSP groups felt less pain than the control group until day 5 (0.6 ! 0.88, 3.75 ! 1.16, 4.75 ! 1.29, and 1.05 ! 1.10, respectively, for the arnica group; 0.35 ! 0.59, 3.25 ! 1.62, 5.0 ! 1.65, and 1.50 ! 1.32 for the MPSP group; and 1.30 ! 1.17, 5.75 ! 1.37, 7.05 ! 1.10, and 3.15 ! 1.53 for the control group; P < .05). The trismus was lower on days 1, 3, and 5 in the arnica group (“8.05 ! 2.82, “12.15 ! 3.1, and “2.15 ! 1.81, respectively) than in the control group (“12 ! 3.82, “15.65 ! 4.81, and “4!2.81, respectively) (P < .05). The edema was lower on days 1 and 3 in the MPSP group (0.95 ! 2.2 and 1.75 ! 3.7, respectively) than in the control group (2.45 ! 0.9 and 3.6 ! 0.8, respectively) (P < .05). Arnica and MPSP had similar pain-relieving action, but arnica was more effective at reducing trismus, while MPSP was more effective at reducing edema.
Conclusions: Topical application of arnica or MPSP may have a beneficial effect on relieving pain 5 days after surgery, but arnica was also effective at reducing trismus, while MPSP was also effective at reducing edema. Both arnica and MPSP reduced postoperative sequelae.
The removal of an impacted mandibular third molar usually causes some degree of pain, swelling, and trismus. This is because the procedure involves surgical trauma in a highly vascularized area, thereby leading to predictable inflammatory complications, also termed ‘‘sequelae.’’1 Pharmacological treatment of the inflammatory response is the most commonly applied method for relieving postoperative sequelae.2,3 Inflammatory mediators (eg, prostaglandins, bradykinin, leukotrienes, and platelet-activating factor) are discharged into the surrounding tissues following surgical intervention. The resulting irritation leads to increases in vascular dilatation and permeability, which trigger subsequent edema and interstitial tissue responses.4,5 Treatment with nonsteroidal antiinflammatory drugs (NSAIDs) is one way of enhancing the patient’s post-surgical comfort.6 Topical creams, such as arnica and mucopolysaccharide polysulfate (MPSP), are agents that can be used for this treatment.7
Arnica (also known as mountain arnica, mountain tobacco, wolf’s bane, and leopard’s bane) has traditionally been used as a topical agent for the treatment of inflammation-related symptoms, such as edema, pain, and malfunction.8,9 A number of studies have shown its positive effect on the inflammation10,11; similar to the effects on the inflammatory cascade12 achieved with topical glucocorticoids.10,13 Arnica’s content may cause allergic reactions and may also prove toxic to healthy tissues14; however, arnica is generally used only topically due to side effects that have been observed following oral administration.11 Besides, MPSP is a semi-synthetic molecule produced through the sulfation of a mixture of glycosaminoglycans derived from mammalian cartilage. It has different therapeutic effects on blood coagulation, the anti inflammatory reaction, and fibrinolysis.7,15,16 It can also be used to suppress edema following orthognathic surgery.17
Discomfort following oral surgery is a primary concern for both patients and clinicians. Synthetic glucocorticoids can be used following the removal of an impacted mandibular third molar as an alternative to nonsteroidal treatment, although some undesirable side effects are associated with their use. The topical application of arnica or MPSP may be considered an alternative treatment approach due to the minimal side effects of these two topical agents. However, information is lacking concerning their effectiveness as treatments for postoperative edema, pain, and trismus after oral surgery.
The purpose of the present study was to determine if topical application of arnica or MPSP reduces pain, trismus, and edema following the removal of impacted mandibular third molars. The following null hypotheses were established: the use of the topical agents would not influence i) pain, ii) maximal mouth opening (MMO), and iii) edema values on postoperative days 1, 3, 5, and 10 following impacted mandibular third molar surgery. The specific aims of the study were: 1) to measure pain, edema, and trismus on postoperative days 1, 3, 5, and 10, and 2) to compare the effectiveness of arnica and MPSP on relieving postoperative pain, edema, and trismus.
Materials and Methods
STUDY DESIGN/SAMPLE
The study population consisted of all patients admitted to the Department of Oral & Maxillofacial Surgery between December 2018 and December 2019 for assessment, management, and removal of an impacted mandibular third molar under local anesthesia. The study protocol was registered at ClinicalTrials.gov (NCT04534426) in August 2020.
All patients were informed about the surgery, the postoperative period, and the possible complications. The study complied with the Declaration of Helsinki in terms of medical protocol and ethics. The regional Ethical Review Board of Abant Izzet Baysal University Local Ethical Committee (2018/284) approved the study, and each patient provided informed consent to participate in the study.
The present randomized controlled trial was designed in accordance with the CONSORT guidelines.18 A parallel-group and single-blinded design was preferred to attain the aims of the study. The patients included in the study had no systemic disease (diabetes, hypertension, hyperthyroidism, hypothyroidism, any cardiac disease, autoimmune disorder, etc), good oral hygiene, Parant level II surgical difficulty,19 no pericoronitis, no drug allergy, and no need for preoperative drugs, and all were older than 16 years of age. The Parant Classification19 levels were as follows: level I, extraction with forceps; level II, extraction through osteotomy only; level III, requiring crown sectioning; and level IV, requiring root section. The exclusion criteria were pregnancy, lactation, smoking, refusal to give informed consent, patients with any missing data or recall visits, and the use of any non-prescribed medicines during the follow-up period.
The patients who met all the inclusion criteria were randomized through a simple randomization method, the closed-envelope approach, and were divided into three groups. The arnica group was treated post-surgically with topical arnica, in addition to undergoing the standard therapy (ST) (use of antibiotic + NSAIDs twice a day). The MPSP group was treated post-surgically with topical MPSP, in addition to undergoing the ST. The control group was treated post-surgically only with the ST. After the surgery, all patients were instructed to bite on gauze for 30 min, clean the region that had been operated on, and refrain from engaging in any form of physical exertion. The patients were also given verbal and written recommendations about soft diets, the use of medications, and oral hygiene. The patients were advised not to apply cooling packs to their cheeks or to engage in mouth-opening exercises to ensure that the effects of the topical agents they were to apply could be evaluated. A systemic antibiotic (1000 mg amoxicillin/clavulanic acid, twice a day; Augmentin, GlaxoSmithKline, Brentford, UK) and a NSAID (50 mg diclofenac potassium, twice a day; Cataflam, Novartis, Stein, Switzerland) were prescribed for all the patients as the standard treatment protocol.
