during the surgical removal of impacted lower third molar teeth , since the region is constricted and the visibility is insufficient and the position and bony structure of the teeth may be rigid , the patient is affected by trauma causing postoperative problems such as pain , edema , decreased function , and trismus . these challenges cause problems for surgeons and patients since they disturb the aesthetics and function . moreover , they may affect the activities of daily living and may result in a severe labor force loss . to prevent all these complications , the most commonly used drugs for the prevention of inflammation after extraction of impacted lower third molar teeth are non - steroidal anti - inflammatory drugs ( nsaids ) . it inhibits cyclooxygenase and the lipoxygenase enzyme , thus preventing the formation of prostaglandins and leukotrienes that play an essential role in inflammation by diminishing active oxygen radicals and inhibiting migration and phagocytosis of leucocytes . in addition to its anti - inflammatory effects by these mechanisms , it also has analgesic and antipyretic effects . corticosteroids are another group of drugs that also suppress the production of prostaglandins and leukotrienes at initial phases and thereby inhibit inflammation . methylprednisolone , a type of corticosteroid , inhibits the development of macrophages in the inflammation zone , diminishing the number and proliferation of fibroblasts in connective tissue , and suppressing the immune system . methylprednisolone , by stabilizing cellular and organelle membranes , reduces kinin and bradykinin formation and blocks histamine and histamine - like substances intracellularly . various routes and times of administration ( e.g. , oral , intravenous , and intramuscular ; preoperative and perioperative ) have recently been proposed because of limited benefits when the therapy was applied postoperatively . although there are many studies in the literature about the effectiveness of corticosteroids and nsaids on reducing complications after the surgical extraction of impacted third molar teeth , there is still no consensus on the type of drug administration . in light of these data , the aim of the present study was to compare the effects of administration of pre - emptive intravenous ( iv ) tenoxicam ( tilcotil roche - istanbul , turkey ) ( an nsaid ) and iv methylprednisolone ( prednol l mustafa nevzat istanbul , turkey ) ( a corticosteroid ) in postoperative control of pain , edema , and trismus of patients following the extraction of impacted third molars . this study was a placebo - controlled , randomized , double - blind , clinical trial . a total of 60 adult patients admitted to our oral and maxillofacial surgery clinic due to impacted third molar teeth , without any known systemic diseases , were included in the study . informed consent was obtained from all patients . to standardize the 60 teeth with an orthodontic indication of surgical extraction in the study , their mesio - angular or vertical positions were recorded . patients who are exposed to severe trauma due to bony retention during surgery were excluded , as were patients who used an anti - inflammatory or analgesic agent during the study or within 15 days prior to the beginning of the study . the ethics committee at dicle university faculty of medicine approved the study , which has been performed in accordance with the ethics standards of the 2008 declaration of helsinki . the patients were randomized into 3 groups according to the drug administered before the operation ; iv 20 mg tenoxicam was administered to group a ( n=20 ) , iv 80 mg methylprednisolone sodium succinate was injected in group b ( n=20 ) , and iv isotonic sodium chloride was administered to group c patients ( n=20 ) 1 hour before the operation . prior to surgery , the patients received extra - oral antisepsis with a solution of 10% povidone - iodine . local anesthesia was performed with lidocaine 2% and epinephrine 1:100 000 . using standard methods , after the surgery , all patients were informed about the local hemostatic measures , feeding , and cleaning . during the postoperative period , prophylaxis amoxicillin 3500 mg , paracetamol 3500 mg as pain - killer , and chlorhexidine gluconate 2x1 times as oral antiseptic were prescribed to all patients . postoperative swelling was assessed by an ultrasound ( toshiba ssh 1401 ) and a 7.5 mhz transducer . in the evaluation of edema , the soft - tissue measurements were performed in dicle university hospital , radiology department , division of ultrasound . the preoperative and postoperative 48 hour ultrasound imaging of all patients were performed from the same point while the teeth were on centric occlusion . to assure that the ultrasound images were taken from the same point , the preoperative measured point was marked with a pen . to achieve maximum standardization , all measurements were performed on the same machine by the same doctor , with minimum pressure on the skin ( figure 1 ) . after the radiological evaluation of all patients , they were asked to open the mouth as much as possible and limited mouth opening ( trismus ) was assessed by determining maximal unassisted mouth opening , measured with a simple calliper between the upper and lower central incisors . the measurement process was repeated 3 times and the mean of these 3 measurements was assessed each time . trismus was determined by the difference between the preoperative and postoperative period . in the evaluation of postoperative pain , visual analogue scale ( vas ) forms were given to the patients . to indicate the intensity of pain , the following categorization was used : 0 = no pain ; 2 = mild pain ; 4 = moderate pain ; 6 = severe pain ; 8= very severe pain ; and 10 = unbearable pain . the patients were asked to mark the pain level hourly during waking hours starting from the first hour of the operation . by use of these forms , the severities of pain were evaluated for the first 24 hours ( figure 2 ) . data analysis was performed using the statistical package for social sciences ( spss for windows , version 18.0 ; spss inc . , chicago , il , usa ) . in the determination of differences between the groups , one - way anova ( variance analysis ) test was used . for the multiple comparisons among groups in variance analysis , dunnett test was used to evaluate the comparison of significant differences between study groups and the control group . postoperative swelling was assessed by an ultrasound ( toshiba ssh 1401 ) and a 7.5 mhz transducer . in the evaluation of edema , the soft - tissue measurements were performed in dicle university hospital , radiology department , division of ultrasound . the preoperative and postoperative 48 hour ultrasound imaging of all patients were performed from the same point while the teeth were on centric occlusion . to assure that the ultrasound images were taken from the same point , the preoperative measured point was marked with a pen . to achieve maximum standardization , all measurements were performed on the same machine by the same doctor , with minimum pressure on the skin ( figure 1 ) . after the radiological evaluation of all patients , they were asked to open the mouth as much as possible and limited mouth opening ( trismus ) was assessed by determining maximal unassisted mouth opening , measured with a simple calliper between the upper and lower central incisors . the measurement process was repeated 3 times and the mean of these 3 measurements was assessed each time . in the evaluation of postoperative pain , visual analogue scale ( vas ) forms were given to the patients . to indicate the intensity of pain , the following categorization was used : 0 = no pain ; 2 = mild pain ; 4 = moderate pain ; 6 = severe pain ; 8= very severe pain ; and 10 = unbearable pain . the patients were asked to mark the pain level hourly during waking hours starting from the first hour of the operation . by use of these forms , the severities of pain were evaluated for the first 24 hours ( figure 2 ) . data analysis was performed using the statistical package for social sciences ( spss for windows , version 18.0 ; spss inc . , chicago , il , usa ) . in the determination of differences between the groups , one - way anova ( variance analysis ) test was used . for the multiple comparisons among groups in variance analysis , dunnett test was used to evaluate the comparison of significant differences between study groups and the control group . the study included a total of 60 patients ( 41 females and 19 males ) aged 1840 years ( table 1 ) . the duration of surgery of groups a , b , and c were 26.100.95 , 25.700.98 , and 23.800.79 minutes , respectively . no significant difference was found between the groups regarding the duration of surgery ( f=1.798 , p>0.05 ) ( table 2 ) . in evaluation of edema , postoperative edema ( subcutaneous + masseter muscle ) ratios of groups were 38% , 57% , and 150% in group a , group b , and control groups , respectively ( p<0.05 ) . there was no statistically significant difference between methyl prednisolone and tenoxicam groups regarding the edema ( table 3 ) . the postoperative trismus ratios of groups were 5.25% , 2.95% , and 13.90% in group a , group b , and the control group , respectively . although the trismus ratios were significantly better in both study groups than in the control group , the methyl prednisolone patients had statistically significantly superior results as regards the trismus compared with the tenoxicam patients ( f=110.3 , p<0.001 ) ( table 4 ) . mean pain scores of groups a , b , and c were 35.305.64 , 48.207.22 , and 81.404.79 , respectively . in the evaluation of pain scores , the tenoxicam and methylprednisolone groups had similar mean pain scores , which were statistically significantly lower than in the control group ( f=15.89 , p<0.001 ) ( table 4 ) . in the follow - up period after single - dose administrations of iv tenoxicam or methylprednisolone , no postoperative complications , including gastrointestinal problems , hemorrhage or delay in wound healing , were observed in any of the patients . although there are many reports in the literature about use of drugs in prevention of postoperative pain , edema , and trismus after impacted third molar teeth extraction , to the best of our knowledge this is the first study comparing the effects of 2 very commonly used drugs moreover , even though this procedure is a very common oral surgical procedure , there is still no consensus about the optimal type , time , method of administration , and dose of drugs to use in prevention of complications . in this respect a gradual facial swelling occurs in response to tissue trauma in the third molar region , with peak swelling 48 h after surgery . there are various methods used in the evaluation of edema after oral surgeries , including visual analogue scale , measuring with silk suture , or by the aid of plethysmography . this effect may be explained by the long duration of action and high anti - inflammatory potencies of both drugs . each drug may be preferred for the purpose of reducing edema after impacted third molar teeth extraction . limited mouth opening is another unwanted effect commonly reported after oral surgeries . in investigations , inter - insical distance measurements before and after the operation is commonly used for the evaluation of trismus , as in our study . trismus impedes eating and talking and reduces the quality of daily life of patients ; in this sense , decreased trismus means decreased discomfort as well as increased life - quality for the patients . therefore , methyl prednisolone may be preferred to tenoxicam for patients with a lesser trismus . in evaluation of postoperative pain , visual analogue scale or number of analgesic tablets consumed after surgery are the methods commonly used . in this study , since patients were prescribed paracetamol 3500 mg routinely after surgery , number of analgesics consumed was not recorded . in pain control , in fact , this is an interesting finding because the exact contribution of corticosteroids in the control of pain is not yet fully clarified , but nsaids are very potent pain - killers . this finding may also be associated with or affected by the use of paracetamol 3500 mg routinely . there is no need to combine corticosteroids ( with their adverse effects ) with nsaids , since combining corticosteroids with a relatively safe drug ( e.g. , paracetamol ) is enough to achieve the same pain - relief . supporting this data , joshi et al . compared the effect of preoperative ibuprofen , diclofenac , paracetamol with codeine , and placebo tablets on postoperative dental pain and found no significant difference between the different therapeutic groups . corticosteroids and nsaids are 2 large groups of drugs that are widely studied for the prevention of postoperative inflammatory complications and to diminish unwanted effects such as pain or trismus [ 1316 ] . nsaids have been reported to be effective in pain relief , while corticosteroids are effective in diminishing edema . this being the case , some investigators preferred to combine these 2 groups of drugs . studied the combined usage of ibuprofen and methylprednisolone in the prevention of pain and edema after third molar teeth extraction and revealed that combined usage of these 2 drugs decreased the edema by 56% and pain by 67% compared with the control group . however , in the present study we did not observe any significant difference between tenoxicam and methylprednisolone groups regarding pain relief . corticosteroids have been used widely in diminishing complications after third molar teeth extraction , but with different dosages and types . .   gave 18 mg oral methylprednisolone 1 night before and 20 mg iv methylprednisolone during surgery and reported that this combination decreased the postoperative edema by 42% within the first 24 h and there was no trismus observed in these patients and no need for other analgesic preparations . investigated the effects of pre - emptive 8-mg oral dexamethasone on pain , trismus and edema of impacted third molar surgery patients and reported that this drug significantly decreased postoperative pain and edema but did not have any effects on trismus . more recently , in a study comparing dexamethasone 8 mg and methylprednisolone 40 mg in control of pain , swelling , and trismus following the impacted third molar teeth extraction , 8-mg dexamethasone has been determined to be better in control of swelling and trismus , with no difference in pain control between drugs . another study comparing the effects of weight - dependent methylprednisolone ( 4080 mg ) or a placebo orally 1 h prior to surgery , determined that a single preoperative weight - dependent administration of methylprednisolone is a safe and effective method for diminishing postoperative discomfort , pain intensity , and total intake of analgesics after wisdom tooth extractions . there are also some studies in the literature comparing the effects of corticosteroids and nsaids on postoperative complications . sisk and bonnington   compared the effects of methylprednisolone and flurbiprofen on postoperative pain , edema , and trismus after impacted third molar teeth surgery on 60 patients aged 1635 years . they determined that flurbiprofen was more effective in pain control while methylprednisolone was more effective in control of edema . compared 50-mg diclofenac with 50-mg diclofenac and 40-mg methylprednisolone combination and reported that the pain scores were diminished in the combined group but there was no significant difference between the groups in terms of trismus . compared the administration of diclofenac potassium alone and in combination with dexamethasone and found that the combination therapy was more effective in controlling pain , swelling , and trismus following third molar surgery . the doses of drugs examined in this study were based on previous reports of the maximum effective dosages without any adverse effects . kumara and zacharias   gave 40 mg tenoxicam to impacted third molar teeth surgery patients  orally to the first group 1 night before the operation and iv to the second group during the operation  and reported that the methods were equally effective in healthy young patients . it has been reported that there was no significant difference between 20 mg or 40 mg iv tenoxicam after oral surgery in terms of pain relief . in light of these data , the recommended dosages range from 40 mg to 125 mg ; however , 80 mg was chosen as it was one of the most commonly used dosages . in a recent study , short - term outcomes of third molar operations ( swelling , trismus , and pain ) has been determined to differ depending on patient characteristics , including age , sex , and body mass index . moreover , in that study surgery characteristics such as operating time and tooth sectioning were also associated with postoperative variables . although the ages were similar , we did not calculate the body mass indices of patients . however , the duration of surgery was recorded and evaluated for each group to determine possible confounding factors that could influence our results . there was no statistically significant difference between groups in the duration of surgery , showing that the procedures , performed by the same surgical team , were as standardized as possible . in conclusion , the results of this study indicate that although methylprednisolone and tenoxicam are both effective in diminishing complications of impacted third molar teeth extraction , preoperative administration of 80 mg methylprednisolone achieves better control of trismus than tenoxicam , without any differences in edema and pain control . in light of these data , we conclude that methylprednisolone may be a better alternative than tenoxicam in the prevention of complications associated with impacted third molar teeth extraction .