Cortisol in Oral and Maxillofacial Surgery: A Double-Edged Sword

Pre-emptive Single Dose of Intramasseteric Administration of Dexamethasone Versus Methylprednisolone in Surgical Extraction of Impacted Mandibular Third Molars: Prospective Split-Mouth, Randomised Triple Blinded Clinical Study

Aim

The study aims to contribute in reducing postoperative sequelae and to determine the optimal corticosteroid for reducing postoperative inflammation, pain, swelling, wound healing and quality of life in patients undergoing surgical extraction of impacted mandibular third molars.

Materials and Methods

The study included 191 patients who presented to the Department of Oral and Maxillofacial Surgery at Thai Moogambigai Dental College and Hospital in Chennai with bilateral impacted mandibular third molars that needed surgical removal. The effects of pre-emptive single dose of dexamethasone and methylprednisolone on pain, oedema, trismus, wound healing, and quality of life after surgical extraction of impacted lower third molars were investigated.

Result

There was no statistical difference between the two steroids, with both achieving identical levels of wound healing and quality of life. On the third postoperative day, there was a statistically significant difference, with methylprednisolone providing clinically superior results in mouth opening and reduction of swelling. However, by the fifth day, both corticosteroids had exhibited identical improvement.

Conclusion

Compared to 8 mg of dexamethasone, 40 mg of methylprednisolone administered as a single preemptive dosage in the intrammaseteric region was associated with enhanced quality of life, a reduction in pain and edema, and almost normal mouth opening.

Activities of the hypothalamo-pituitary-adrenal axis and autonomic nervous system following a strong earthquake

This study aimed to investigate the effects of post-traumatic stress, caused by a strong earthquake, on the hypothalamo-pituitary-adrenal axis (HPA) and autonomous nervous system activity (ANS). Activities of the HPA (as salivary cortisol) and ANS (as heart-rate variability [HRV]) were measured following the 2020 Elazig (Türkiye) earthquake (6.8 Richter Scale, classified as strong). A total of 227 participants (103 men (45%) and 124 women (%55)) provided saliva samples twice, namely, 1 week and 6 weeks after the earthquake. Of these participants, HRV was measured in 51 participants by 5 min continuous electrocardiogram (ECG) recording. Frequency- and time-domain parameters of the HRV were calculated to assess the activity of ANS and low/high frequency (LF/HF) ratio was used as surrogate for sympathovagal balance. Salivary cortisol levels decreased from week 1 towards week 6 (17.40 ± 1.48 and 15.32 ± 1.37 ng/mL, respectively, p < 0.05). There were no gender differences (17.99 ± 2.63 and 16.90 ± 1.60 ng/mL, respectively for females and males, p > 0.05) for salivary cortisol levels. There were no differences in time- and frequency domain parameters of the HRV including LF/HF ratio (2.95 ± 0.38 ms2 and 3.60 ± 0.70 ms2 , respectively for week 1 and 6, p > 0.05). The data show that HPA axis activity, but not that of the ANS, remains higher 1 week after the earthquake but decreases afterwards towards the sixth week, suggesting that the HPA axis might be responsible for the long-term effects of a traumatic event like a strong earthquake.

Efficacy of Hydrocortisone, Povidone-Iodine, and Normal Saline as an Irrigating Solution During Surgical Removal of Impacted Mandibular Third Molars: A Randomized Controlled Trial

Background The surgical removal of mandibular third molars is one of the most common procedures in dentistry. Researchers have extensively studied the treatment of postoperative sequelae such as pain, edema, trismus, and alveolar osteitis throughout the past six decades. Many approaches have been used to address clinical difficulties after third molar surgery, including various flap designs and irrigating solutions. The aim of this study was to compare the effects of three irrigating solutions, hydrocortisone, povidone-iodine, and normal saline, on pain, trismus, and edema following surgical removal of the impacted mandibular third molar. Methodology The study involved 105 participants who required surgical extraction of mandibular third molars. The patients' ages ranged from 18 to 40 years, and they fulfilled the inclusion criteria. Using a simple random sampling technique, they were divided into three groups (group 1: hydrocortisone, group 2: povidone-iodine, group 3: normal saline). The parameters evaluated were edema, pain, and trismus on the second and seventh postoperative days. All data were input into Microsoft Excel (Microsoft® Corp., Redmond, USA) worksheets and analyzed using Stata 17.0 (StataCorp LLC, College Station, USA). The visual analog scale (VAS) score was used to measure postoperative pain, and postoperative swelling was measured using linear measurements from four fixed anatomical points and compared to preoperative values. To assess trismus, the inter-incisal distance was measured in millimeters with a caliper. A p-value of <0.01 was considered statistically significant. Results The mean VAS score for pain in group 1 was lower than the other two groups. The effect of group 1 was significant on the second postoperative day but insignificant on the seventh postoperative day for swelling. The effect of all three groups on trismus was significant on the second and seventh days. Conclusions Hydrocortisone as an irrigating solution showed promising results in managing postoperative swelling in the first 48 hours, but its effect gradually declined by the seventh postoperative day. Additionally, it was effective in controlling postoperative pain and trismus. This suggests that utilizing hydrocortisone as an irrigating solution, compared to povidone-iodine, has been proven to be a significantly effective option in reducing postoperative pain, edema, and trismus resulting from the surgical removal of impacted teeth.

A Patient with Addison Disease (Primary Adrenal Insufficiency) Presenting for Surgical Extraction of Third Molars

The local prevalence of primary adrenal insufficiency (PAI) depends on various factors such as genetics, environment, and timely disease diagnosis. PAI is uncommon, and the prevalence is reported to be 2 per 10,000 population. PAI is commonly caused by an autoimmune process that destroys the adrenal gland, resulting in the loss of glucocorticoid and mineralocorticoid secretion from the adrenal cortex. The lack of cortisol results in impaired glucose/fat/protein metabolism, hypotension, increased adrenocorticotropic hormone secretion, impaired fluid excretion, and hyperpigmentation. PAI has a female predominance and is commonly seen in ages 20 to 50 years but can occur at any age.

Antioxidant and antiradical activities depend on adrenal tumor type

The aim of the study was to assess the total antioxidant/oxidant status in the plasma and urine of patients with adrenal tumors. The study group consisted of 60 patients (31 women and 29 men) with adrenal masses, classified into three subgroups: non-functional incidentaloma, pheochromocytoma and Cushing's/Conn's adenoma. The number of patients was set a priori based on our previous experiment (α = 0.05, test power = 0.9). Antioxidant activity (Total Antioxidant Capacity (TAC), Total Oxidant Status (TOS), Oxidative Stress Index (OSI)) and antiradical activity (Radical-Scavenging Activity Assay (DPPH), Ferric-Reducing Antioxidant Power (FRAP)) were measured using colorimetric methods. FRAP level was decreased in plasma and urine incidentaloma (p<0.0001), pheochromocytoma (p<0.0001) and Cushing's/Conn's adenoma (p<0.0001), while DPPH antiradical activity only in plasma of patients with adrenal masses (p<0.0001). Plasma TAC was increased in incidentaloma patients (p=0.0192), whereas in pheochromocytoma group (p=0.0343) was decreased. Plasma and urine TOS (p<0.0001) and OSI (p<0.01) were significantly higher in patients with adrenal tumors. In pheochromocytoma patients, plasma and urine TAC (p=0.001; p=0.002), as well as plasma plasma DPPH (p=0.007) and urine FRAP (p=0.017) correlated positively with normethanephrine. We are the first who showed reduced radical scavenging capacity in the plasma/urine of patients with adrenal masses. Nevertheless, plasma TAC was significantly higher in the incidentaloma group compared to controls. Therefore, plasma and urinary antioxidant and antiradical activities depend on the presence of the tumor. Lower levels of TAC, DPPH and FRAP clearly indicate a reduced ability to scavenge free radicals and thus a lack of effective protection against oxidative stress in patients with adrenal tumors. Both plasma and urine redox biomarkers can be used to assess systemic antioxidant status in adrenal tumor patients.

Cross-Talk Between Nitrosative Stress, Inflammation and Hypoxia-Inducible Factor in Patients with Adrenal Masses

Background

Adrenal masses are the most common of all human tumors. The role of nitrosative stress and inflammation in cancer development has already been demonstrated. However, it is not known whether they are involved in the pathogenesis of adrenal tumors. The aim of the study was to investigate a cross-talk between nitrosative stress, inflammation and hypoxia-inducible factor (HIF-1α) in 75 patients with different types of adrenal masses (non-functional incidentaloma, pheochromocytoma and Cushing's/Conn's adenoma).

Methods

The plasma concentrations of total nitric oxide (NO), S-nitrosothiols, peroxynitrite nitrotyrosine and the activity of serum myeloperoxidase (MPO) were measured spectrophotometrically, whereas concentrations of interleukin 1 beta (IL-1β), tumor necrosis factor α (TNF-α) and hypoxia-inducible factor 1 alpha (HIF-1α) were measured using commercial ELISA kits. The control group consisted of 50 healthy people matched by age and sex to the study group. The number of subjects was determined a priori based on our previous experiment (power of the test = 0.9; α = 0.05).

Results

We found significantly higher nitrosative stress (↑nitric oxide, ↑peroxynitrite, ↑S-nitrosothiols and ↑nitrotyrosine) in the plasma of patients with adrenal tumors, which was accompanied by increased inflammatory (↑myeloperoxidase, ↑interleukin 1 beta and ↑tumor necrosis factor α) and hypoxia (HIF-1α) biomarkers. Peroxynitrite and nitrotyrosine were positively correlated with aldosterone level. Nitrosative stress was also associated with inflammation and HIF-1α. Interestingly, plasma nitrotyrosine and serum MPO differentiated patients with adrenal tumor from healthy individuals with high sensitivity and specificity. Moreover, using multivariate regression analysis, we showed that ONOO^- and IL-1β depended on cortisol level, while ONOO^-, nitrotyrosine and HIF-1α were associated with aldosterone. Unfortunately, none of the assessed biomarkers differentiated between tumor types studied, suggesting that the severity of nitrosative damage and inflammation are similar in patients with incidentaloma, pheochromocytoma, and Cushing's or Conn's adenoma.

Conclusion

Adrenal tumors are associated with increased protein nitration/S-nitrosylation and inflammation.