An interesting article titled “Oral Bromelain for the Control of Facial Swelling, Trismus, and Pain After Mandibular Third Molar Surgery: A Systematic Review and Meta-Analysis,” appears in the 2019 edition of the Journal of Oral and Maxillofacial Surgery written by Liu et al. The article seeks to explore if bromelain reduces pain and swelling and improves mouth opening after wisdom teeth removal. Bromelain is believed to decrease swelling by returning interstitial fluid and inflammatory component cells into the bloodstream and provide an anti-inflammatory effect by decreasing pain mediators such as prostaglandin E2 and substance P.
Bromelain provides for systemic proteolytic enzyme therapy and is a mixture of proteolytic enzymes found in pineapple plants. The authors state a few articles in the past have explored using bromelain after wisdom teeth removal but with inconsistent results. For example one study showed bromelain after wisdom teeth surgery decreased inflammation and improved mouth opening but the results did not reach statistical significance. The authors thus performed a systematic review and meta-analysis to look for evidence that bromelain could influence mouth opening, pain, and facial swelling after extracting lower wisdom teeth. The authors identified studies that were randomized controlled trials (RCTs) with sufficient data that explored the effect of bromelain with placebo after wisdom teeth surgery in humans and reported at least one of the effects of swelling, trismus (lack of mouth opening), pain, wound healing, and side effects. To assess whether bromelain had an impact the authors calculated the pooled weighted mean difference or standardized mean difference with the corresponding 95% confidence intervals. The authors arrived at 6 articles that were included in their systematic review and meta-analysis all of which compared bromelain to placebo after wisdom teeth removal and looked at pain, swelling, and trismus.
When exploring facial swelling five of the six studies that were used had 158 extractions with bromelain and 162 extractions with placebo in 252 patients. It was found on the second or third day after surgery (referred to later as early stage) that the extractions with bromelain had decreased swelling when compared to without, a statistically significant result. The authors also assessed swelling on the seventh day after surgery (referred to later as late stage) and found that bromelain also decreased swelling when compared to without using it. When exploring early pain three of the six studies that were used had 139 patients who received bromelain and 141 patients who received placebo. It was found that bromelain had no effect on early pain. When exploring late pain three of the six studies that were used had 71 patients who received bromelain and 73 patients who received placebo. It was found that among patients who received bromelain on the seventh day after surgery they had significantly decreased pain when compared to those that did not. Three of the studies also showed that those who used bromelain also used less as needed analgesic medications than those who did not receive bromelain. When exploring trismus or reduced mouth opening three of the six studies that were used had 50 patients who received bromelain and 52 patients who received placebo. There was no differences among those who received bromelain or who did not with regards to both early and late trismus.
The authors believe that bromelain could be as effective as both corticosteroids and nonsteroidal anti-inflammatory drugs after wisdom teeth surgery. The authors feel the results they found are credible but do point out a few limitations. One limitation was that there was not consensus on the amount of bromelain given. Another limitation was that the samples included in the trials were small. A further limitation was that the authors essentially made up standard deviations of some values for analysis in their study based on conservative estimates when they were not available in the study.