Comparison of the efficacy of aescin and diclofenac sodium in the management of postoperative sequelae and their effect on salivary Prostaglandin E2 and serum C–reactive protein levels after surgical removal of impacted mandibular third molar: a randomized, double-blind, controlled clinical trial.

Background and rationale

The backbone of most oral surgical practices worldwide is the extraction of impacted third molars. It is the most common oral surgical procedure¹ performed in dental offics. However, the postoperative phase is often concomitant with severe pain, reduced mouth opening, and marked facial inflammation. Most patients are prescribed corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) to manage their postoperative discomfort. NSAIDS have been associated with gastrointestinal bleeding, disturbance in renal function, and a reduction in platelet count.² Because of these limitations, many phytotherapeutic alternatives have been suggested. Aescin (Escin) has generated interest among researchers over the years. It is a practical part of Aesculus hippocastanum and was first isolated in 1953. It combines triterpene saponins and has demonstrated anti-inflammatory, antiedematous, and venotonic properties in various preparations.³ Thus, the present study demonstrates the utility of aescin in managing postoperative discomfort after the surgical removal of impacted mandibular third molars.

Another concern over the years has been the selection of NSAIDs, which predominantly depends on subjective factors, including the surgeon’s preference and personal experience. The need for an hour is to use a measurable marker of inflammation that can be quantitatively controlled by drug administration. Prostaglandin E2 (PGE2) is a reliable marker of inflammation, which has been isolated from various body fluids, including saliva.⁴ Owing to inflammation, C-reactive protein (CRP) emerges in the blood. Various studies have used CRP concentrations to monitor the healing process after drug therapy because of its sensitivity.⁵ This study aimed to correlate salivary PGE2 levels and serum C-reactive protein levels with subjective and objective symptoms after surgical extraction of the mandibular third molar and their relationship with drug therapy.

Background and rationale: choice of comparators

Diclofenac was chosen for comparison because it has dose equivalence to aescin and is widely used to manage postoperative sequelae associated with third molar surgery.

Aim of the study

To compare the efficacy of aescin (escin) and diclofenac in managing postoperative sequelae following surgical removal of impacted mandibular third molars and their effects on salivary Prostaglandin E2 and serum C-reactive protein levels.

Trial design

A single-center, double-blind, randomized, parallel, prospective clinical trial will be conducted at the Sharad Pawar Dental College, Datta Meghe Institute of Higher Education and Research (DMIHER), Sawangi, Wardha.

Two groups will be created:

Group A – Diclofenac sodium

Group B – Aescin (escin)

The randomization process will be performed using a computer-generated subject allocation list.

Trial participants and outcome assessors will be blinded.

Study setting

A total of 50 patients presenting to the outpatient department of oral and maxillofacial surgery, Sharad Pawar Dental College and Hospital, Sawangi, Wardha, India, with impacted mandibular third molars with a definitive indication for extraction will be enrolled in the study.

Eligibility criteria

Inclusion criteria

Exclusion criteria

Interventions: description

A clinical trial will be conducted with approval from the institutional ethics committee. The Consolidated Standards of Reporting Trials (CONSORT) statement guidelines will be used for this study.

Patients will be prescribed either diclofenac sodium 150 mg/day or aescin (escin) 120 mg/day⁶ to be taken orally in divided doses for five days. Each patient will be subjected to one of the drugs after the procedure.

Saliva collection will be done using a sterile polystyrene tube. A kit specific to PGE2 will be used to measure PGE2 levels in each specimen.⁴

Venous blood will be subjected to a C-reactive protein (CRP) test to measure C-reactive protein⁷ levels in blood serum.

Saliva and serum samples will be processed in Central Research Laboratory.

Surgical procedure

All patients will be administered 1 g of oral amoxicillin 1 h before the procedure. The standard surgical protocol for the removal of impacted mandibular third molars under local anesthesia will be followed.

Interventions: modifications

Drug therapy will be discontinued in cases of adverse reactions reported by the patient.

Interventions: adherence

Patients will be recalled on the second and fifth postoperative days. The number of tablets remaining will be calculated to assess compliance with the trial protocol.

Interventions: concomitant care

Patients will be required to adhere to the standard postoperative instructions following extraction.

Tramadol 50 mg will be prescribed as a rescue analgesic for the postoperative period.

Participant timeline

Pain, facial swelling, mouth opening, serum C-reactive protein, and salivary prostaglandin E2 levels will be recorded preoperatively (T0) on the second postoperative day (T1) and fifth postoperative day (T2).

Patient satisfaction regarding therapy and the need for rescue analgesics will be recorded on the fifth postoperative day.

Sample size

The study will be a non-inferiority trial with a continuous outcome.

The sample size was established based on data obtained from a previous study conducted by Salgia et al.¹⁰ Serum C-reactive protein level was chosen as the primary outcome variable.

Formula using mean difference

α = Type I error at 5% at both sides two tailed

Z_β = 0.84 = Power at 80%

Primary Variable = CRP (C-reactive protein) levels

The mean difference after treatment CRP (mean ± SD) for the diclofenac group was 16.305 ± 3.977 (as per the reference article).⁹

Considering 20% clinically relevant margin for aescin = ($16.305\ast 20)/100=3.26$

Sample size:

Assuming 10% dropout = 2

Total sample size required = 23 + 2 = 25 each group.

Thus, a total sample size of 50 subjects presenting with impacted mandibular third molars will be enrolled in the study.

Recruitment

All patients presenting to the outpatient unit of the Oral and Maxillofacial Department and fulfilling the enrolment criteria of the study will be recruited. The principal investigator coordinated with each patient to achieve the desired sample size.

Allocation: sequence generation

Study participants will be randomized using the SCIENCER application. As a specific age range was chosen for the study, further stratification and subset creation will not be performed.

Allocation concealment mechanism

All the patients will be sequentially numbered for the purpose of allocation concealment.

Allocation: implementation

The principal investigator will then enrol the participants. The research supervisor allocate the sequence and assign the participants to the intervention.

Blinding

Trial participants and the principal investigator will be blinded.

Blinding (masking): emergency unblinding

Unblinding will be performed if a patient reports adverse side effects to the emergency unit during the follow-up period.

Data collection plan

Demographic, clinical, and laboratory data for each patient will be collected using the JOTFORM application.

Data collection plan: retention

Telephonic reminders will be administered to each patient, according to the follow-up protocol. The research supervisor will directly dispense medication to the participants to promote retention.

Data management

Demographic, clinical, and laboratory data will be segregated in the JOTFORM application based on patient codes. The filtered data will be downloaded and stored in an Excel spreadsheet for statistical analysis.

Statistical analysis plan

Statistics: outcomes

Statistics: additional analyses

Statistics: analysis population and missing data

Primary variable

Inferential statistics will be used to compare the two groups for measurement scores, resulting in their mean change in a primary variable (visual analog scale, facial swelling, mouth opening, salivary prostaglandin E2, serum C-reactive protein) between baseline and end visits.

Baseline variables will be tested for significance in the mean using ANOVA or Kruskal-Wallis test for more than two assessment periods. A post-hoc (Tukey’s or Duncan’s) test will be used to find a significant difference between the two groups for pair-wise comparison.

Outcome variables

Outcome variables will be tested for intra-difference in measurement at pre- and post-visits using a paired t-test to determine the mean’s significance. The unpaired t-test for comparison of two groups and ANOVA for comparison of three groups will be used for intergroup differences.

Statistical analysis will be carried out using R-software free version.

Data monitoring: formal committee

Data monitoring will be carried out under the aegis of DSCC at DMIHER, Sawangi, and Wardha.

Data monitoring: interim analysis

The interim analysis and review will be carried out by a member of the institutional ethics committee. Trial termination rights were reserved by the Institutional Ethical Committee.

Harms

Telephonic conversations will be conducted prior to follow-up visits to inquire about any untoward events. In case of any adverse events, patients will be managed at the institutional hospital, and the necessary care will be rendered free of cost.

All adverse events will be reported to the Institutional Ethical Committee.

Auditing

An interim audit of the trial will be conducted by the research supervisor. A final audit will be carried out by nominated members of the DSCC at the DMIHER, Sawangi, and Wardha.

Ethics and dissemination

Research ethics approval

Ethical approval has been obtained from the Institutional Review Board of the Datta Meghe Institute of Medical Sciences (now renamed as Datta Meghe Institute of Higher Education and Research) Sawangi, Wardha. (Reference number: DMIMS (DU)/IEC/2022/842 on 05/04/2022).

Protocol amendments

Amendments to the protocol will be carried out only after approval from the Institutional Ethical Committee and DSCC at DMIHER, Sawangi, Wardha.

Consent or assent

The Principal investigator will be required to answer any queries by the patient regarding the trial, and will be responsible for obtaining informed consent.

Consent or assent: ancillary studies

No biological specimen will be stored for ancillary studies and hence, ancillary study consent is not applicable.

Confidentiality

Access to information from individual participants will be restricted to the principal investigator and research supervisor.

Declaration of interests

There are no financial or competing interests for the principal investigators for the overall trial or each study site.

Data access

The principal investigator and research supervisor will be custodian of the final trial data. The IEC and DSCC have access to the final trial dataset.

Ancillary and post-trial care

The trial will be conducted in accordance with good clinical practice and a strong adverse event-monitoring protocol. The safety of the procedures and drugs used in this study has been established. However, in case of any harm, compensation will be carried out according to institutional policy.

Dissemination policy: trial results

This clinical trial will be published as an original research article in an indexed journal. Open access release of the trial results will be performed to ensure optimum exposure of the scientific community.

Dissemination policy: authorship

The final trial data will be published as postdoctoral research (PHD thesis). The authorship associated with this trial will be limited to the principal investigator and research supervisor, with acknowledgements to individuals involved at various stages of the trial.

Dissemination policy: reproducible research

The PHD thesis will be made public after approval from DSCC.

Study status

The study is currently in the stage of a pilot project.