Risk Factors for Inflammatory Complications Following Third Molar Surgery in Adults

Development of a risk prediction model for surgical site infection after lower third molar surgery

BACKGROUND

There is little evidence regarding risk prediction for surgical site infection (SSI) after lower third molar (L3M) surgery.

METHODS

We conducted a nested case-control study to develop a multivariable logistic model for predicting the risk of SSI after L3M surgery. Data were obtained from Hokkaido University Hospital from April 2013 to March 2020. Multiple imputation was applied for the missing values. We conducted decision tree (DT) analysis to evaluate the combinations of factors affecting SSI risk.

RESULTS

We identified 648 patients. The final model retained the available distal space (Pell & Gregory II [p = 0.05], Pell & Gregory III [p < 0.01]), depth (Pell & Gregory B [p < 0.01], Pell & Gregory C [p < 0.01]), surgeon's experience (3-10 years [p = 0.25], <3 years [p < 0.01]), and simultaneous extraction of both L3M [p < 0.01]; the concordance-statistic was 0.72. The DT analysis demonstrated that patients with Pell and Gregory B or C and simultaneous extraction of both L3M had the highest risk of SSI.

CONCLUSIONS

We developed a model for predicting SSI after L3M surgery with adequate predictive metrics in a single center. This model will make the SSI risk prediction more accessible.

The Effects of a Cool Saline Solution Irrigation on Mandibular Third Molar Extraction Site: A Postoperative Split-Mouth Evaluation

OBJECTIVE

This study aimed to evaluate the effects of sterile saline solution irrigation (lavage) performed after mandibular third molar extraction on postoperative complications, utilizing a split-mouth randomized clinical trial design.

METHODS

Seventeen healthy participants requiring bilateral mandibular third molar extraction were enrolled in this single-center study. In each participant, one impacted third molar was designated as the experimental group and subjected to saline lavage at 4 °C. In contrast, the control group was the other impacted third molar, undergoing saline lavage at 25 °C. Various parameters, including postoperative pain, mouth opening, and facial swelling, were assessed using standardized measures and three-dimensional facial scanning at multiple time points.

RESULTS

The average age of participants was 26.66 ± 4.1 years, with no postoperative complications observed in either group. The duration of surgery did not significantly differ between groups. Postoperative pain was significantly reduced in the experimental group during the immediate postoperative period compared with the control group, but this difference diminished over time. No significant differences were observed in mouth opening or facial swelling between groups at any time.

CONCLUSION

In site 4 °C, sterile saline solution irrigation after mandibular third molar extraction may effectively reduce early postoperative complications, particularly pain, without prolonging surgical duration.

Efficacy and safety of parenteral and local application of tramadol in mandibular third molar extraction: a qualitative systematic review of current evidence

PURPOSE

To assess the efficacy and safety of perioperative parenteral administration or submucosal infiltration of tramadol for perioperative pain control on the basis of pain intensity or analgesics consumption and perioperative outcomes in mandibular third molar surgery.

MATERIAL-METHODS

An electronic database search was conducted up to 10 November 2022 to retrieve all randomized controlled trials (RCTs), assessing the analgesic efficacy of parenteral use of tramadol implemented as an adjunct to local anesthesia or intraoperative sedation/general anesthesia, in surgical extraction of mandibular third molars. Modified Jadad scale and Cochrane bias tool were used for the qualitative appraisal.

RESULTS

Nineteen RCTs were selected for qualitative analysis. Nine studies involved intravenous, and 5 intramuscular administration of tramadol, while 5 evaluated submucosal infiltration with tramadol. Intravenous or intramuscular tramadol provided a weaker analgesic effect compared with non-steroidal anti-inflammatory drugs (NSAIDs), while intravenous tramadol induced an enhanced analgesic effect than oral tramadol. Parenteral administration of tramadol improved the quality of postoperative analgesia versus placebo. No notable adverse effects were recorded.

CONCLUSIONS

Parenteral or submucosal infiltration of tramadol constitutes an effective and safe alternative analgesic approach in surgical extraction of mandibular third molars, yet the nociceptive effect of this analgesic modality could not supersede that of NSAIDs.

TRIAL REGISTRATION

PROSPERO No CRD42021227574.

Prevalence and Factors Influencing Post-Operative Complications following Tooth Extraction: A Narrative Review

Background

Complications from dental extractions may result in multiple post-operative visits and adversely affect the patient's life. Preventing complications may decrease post-operative morbidity for the individual as well as lower societal costs, such as lost time from work and healthcare costs.

Objectives

This narrative review aims to assess the prevalence and factors influencing post-operative complications following tooth extraction, helping clinicians minimise the risk. Data Sources. Cross-sectional studies. Study Eligibility and Participants. Patients undergoing dental extractions. Our exclusion criteria included in vitro studies, animal studies, terminally ill patients, and tooth loss not due to dental extraction. Literature was collected from "PubMed" and "Web of Science" through search criteria based on the "PICO" framework. Twenty articles were used to formulate a prevalence table, and 156 articles were included for the factors influencing complications. Study Appraisal and Synthesis Methods. This narrative review was reported using the SANRA (a scale for the quality assessment of narrative review articles) checklist. Due to the scope of our narrative review and its associated objectives, the quality of cross-sectional studies (AXIS) will be conducted from the studies outlining the prevalence.

Results

Alveolar osteitis appears to be the most prevalent post-operative complication following tooth extraction. Predisposing factors can be significant in their ability to alter the risk of postoperative complications, and clinicians should provide patient-centred care to mitigate this risk. Limitations. Due to the breadth of context, a systematic review was not feasible, as it may have introduced heterogeneity.

Conclusion

This narrative review has highlighted an array of factors which can influence the prevalence of post-operative complications. Future research would benefit from individually reporting post-operative complications, reducing the heterogeneity in definitions of the complications, and including greater detail on the predisposing factors studied.

[Classification of lower impacted third molars position and their interrelationship with mandibular canal]

Classification of lower Impacted third molars position and their interrelationship with mandibular canal have a great scientific, theoretical and practical importance. An attempt to systematize and classify all anatomical impacted third molars position has been made by many authors. Based on our scientific literature search, we found: 8 impacted third molars classifications, 7 third molars and mandibular canal interposition classifications, as well as 5 classifications of mandibular canal anatomical branching variants. Most classifications are proposed by the author to predict third molar eruption perspective, determine level of operation complexity and prevent mandibular canal damage. New clinical classification development of impacted third molars interrelationship with mandibular canal, which combined the radiological PR, CBCT criteria, neurovascular bundle trauma prognosis, and operative technic choice can be actual.

Previous dry socket as a risk factor for alveolar osteitis: A nested case-control study in primary healthcare services

Background

Dry socket is one of the most common complications following tooth extraction, though no studies have been made on its main risk factors in the primary healthcare services of Barcelona (Spain). Objectives: To analyze the influence of different factors upon the appearance of dry socket in patients attended in the primary care setting, and to determine the possible presence of risk factors in patients who have suffered a previous episode of dry socket.

Material and Methods

During 24 months, questionnaires were filled with data on the patients seen in different public primary healthcare services in the area of Barcelona (Spain). A case-control study was conducted to identify the main risk factors for developing complications in the form of dry socket.

Results

A mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and previous dry socket increased the risk of developing this complication. In patients with dry socket in the past, the risk of developing the same complication again, adjusted for difficulty of extraction, was seen to increase 11.45-fold (OR: 11.45; 95%CI: 1.06 to 123.74; p = 0.045).

Conclusions

The risk factors for dry socket are a mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and particularly a history of dry socket in the past. The identification of these factors the prevention of dry socket in each patient could be improved.

Key words:Dry socket, risk factors, extraction, complications.

Can Teledentistry Replace Conventional Clinical Follow-Up Care for Minor Dental Surgery? A Prospective Randomized Clinical Trial

(1) Background: Born out of necessity, the implementation of digital processes experienced significant increase during the COVID-19 pandemic. Here, telemedicine offered a bridge to care and now an opportunity to reinvent virtual and hybrid care models, with the goal of improved healthcare access, outcomes, and affordability. The aim of this monocentric prospective, randomized trial was to compare conventional to telephone follow-up after minor dentoalveolar surgery on the basis of special aftercare questionnaires. (2) Methods: Sixty patients who underwent dentoalveolar surgery under local anesthesia were randomly assigned to both groups. After an average of four days, either telephone follow-up (test) or conventional personal aftercare (control) was performed. Based on the questionnaire, the following subject areas were evaluated: symptoms, complications, satisfaction with practitioner, travel, and waiting time, as well as the preferred form of follow-up care. (3) Results: There was no statistically significant difference regarding frequency of symptoms or complication rate. Patients who were assigned to the test group showed a clear tendency to prefer telephone follow-up (83.3%) to conventional aftercare (16.7%, p = 0.047). (4) Conclusions: The data suggest high acceptance of telephone-only follow-up after dentoalveolar surgery. The implementation of telemedicine could be a time- and money-saving alternative for both patients and healthcare professionals and provide healthcare access regardless of time and space.

The use of advanced platelet-rich fibrin after surgical removal of mandibular third molars: a systematic review and meta-analysis

The objective of this systematic review was to test the hypothesis of no difference in recovery following surgical removal of mandibular third molars with the application of advanced platelet-rich fibrin (A-PRF) in the extraction socket compared with alternative biomaterials or natural wound healing. A search of MEDLINE (PubMed), Embase, Cochrane Library, and Scopus was conducted. Human randomized controlled trials published in English up until December 31, 2020 were included. Outcome measures were pain, facial swelling, trismus, soft tissue healing, alveolar osteitis, and quality of life; these were evaluated by descriptive statistics and meta-analysis including 95% confidence intervals (CI). Four studies with a low or moderate risk of bias fulfilled the inclusion criteria. A-PRF resulted in significantly lower pain scores when compared with leucocyte platelet-rich fibrin or natural wound healing after 2 days (-16.8, 95% CI -18.9 to -14.7), 3 days (-12.1, 95% CI -13.4 to -10.7), and 7 days (-1.9, 95% CI -2.9 to -0.9). A-PRF seems to have a negligible effect on facial swelling and trismus and some beneficial effect on soft tissue healing. Alveolar osteitis and quality of life were not assessed. The included studies were characterized by considerable heterogeneity and confounding variables. Thus, the level of evidence appears to be inadequate for clinical recommendations according to the focused question.

Prevalence of Postoperative Infection after Tooth Extraction: A Retrospective Study

The aim of the study was to identify the postoperative infection rates after tooth extraction in a university dental clinic and to identify the factors associated with an increased risk for postoperative infection. A retrospective study of case records of patients who underwent tooth extractions at the International Medical University's Oral Health Centre (IMU-OHC) over a span of 6 years was conducted. Data on demography, patient-related factors, and treatment-related factors were extracted from the case records. A binary logistic regression analysis was performed to assess the odds ratio of a patient having a postoperative infection or not, comparing it with each variable. A total of 1821 extractions, including simple and complex extractions, were performed over 6 years. Only 25 (1.4%) of the cases were reported to have a postoperative infection. The complexity of the extraction was the only variable that significantly affected the occurrence of postoperative infection after extraction; more complex extractions were reported with higher rates of infection (binary logistic regression, OR = 2.03, p = 0.004). None of the other factors, including antibiotic prescription, had a significant influence on the occurrence of postoperative infection. The prevalence of postoperative infection after dental extractions was low in IMU-OHC, and prescribing antibiotics had no added advantage in the prevention of postoperative infection.

Third Molar Extraction: Irrigation and Cooling with Water or Sterile Physiological Solution: A Double-Blind Randomized Study

BACKGROUND

The present study aimed to ascertain whether any significant reduction in patients' postoperative pain and inflammation could be achieved by using sterile physiological solution instead of normal water to irrigate the surgical field and cool the dental bur during third molar extractions.

METHODS

The study concerned 22 patients (11 females and 11 males) in good general health, who were referred to the Dental Clinic at Padova University hospital for lower third molar extractions. They were randomly assigned to two groups. Only the fluid used to irrigate the surgical field and cool the dental bur differed between the two study groups, being sterile physiological solution for group A, and mains water for group B. Postoperative pain, swelling, trismus and inflammation with high sensitivity CRP where measured and statistically evaluated. The numerosity of our sample was calculated on the grounds of an endpoint based on data in the literature.

RESULTS

Eighteen patients needed bilateral extractions, and 4 required only one extraction, so a total of 40 third molars were extracted. A sterile physiological solution was used to irrigate the surgical field in 20 extractions, while water was used in the other 20 cases. Data analysis with Wilcoxon test show no differences between the two groups (p < 0.05).

CONCLUSIONS

no differences between groups for any of the parameters considered, after third molar extraction procedures undertaken using either sterile physiological solution or water for irrigation and cooling purposes.

Incidence of hypercementosis in mandibular third molars determined using cone beam computed tomography

PURPOSE

This study was conducted to investigate the incidence and predictors of hypercementosis in mandibular third molars using cone beam computed tomography.

METHODS

Using a retrospective approach, 1,160 cone beam computed tomography image sets were analyzed. Two oral radiologists independently evaluated the image sets based on four severity grades: 0, no hypercementosis around the root; 1, hypercementosis surrounding less than half of the root surface; 2, hypercementosis surrounding more than half of the root surface; and 3, hypercementosis surrounding the entire root surface. Hypercementosis was identified as a dark or light layer. Statistical analyses of relationships between hypercementosis incidence and possible predictors (e.g. age, sex, impaction, and occlusion) were performed using chi-square test or Fisher's exact test; logistic regression was used for multivariate analysis.

RESULTS

The severity of hypercementosis increased with age, and the incidences were as follows: ≤19 years, 0%; 20-24 years, 14.1%; 25-29 years, 57.7%; 30-39 years, 83.0%; 40-49 years, 92.7%; 50-59 years, 93.4%; and ≥60 years, 96.8%.

CONCLUSION

The observed incidences of hypercementosis were relatively higher than in previous studies, and the incidence was significantly lower for occluded teeth than for non-occluded teeth.

Indications of the extraction of symptomatic impacted third molars. A systematic review

Background

A literature review was made to determine when third molar (3M) extraction is recommended in symptomatic patients and when it is not recommended.

Material and Methods

A Medline (PubMed) and EMBASE search was made for articles related to indications for the extraction of 3Ms, published in the last 10 years and up until September 2018.

Results

The electronic search yielded 175 articles. After eliminating duplicates, a total of 173 articles were subjected to review of the title and abstract. Only 19 studies were finally included in the systematic review. There was a well documented increase in morbidity associated to impacted 3Ms (non-restorable caries, fracture, infection, periodontal disease, repeated pericoronitis, cysts and tumors), and in the presence of disease, extraction was considered to be indicated. The extraction of 3Ms with signs and/or symptoms of periodontal disease improved periodontal health at the distal surface of the second molar. Postoperative quality of life of patients with symptomatic 3Ms and with disease improved after surgical extraction.

Conclusions

Extraction is indicated in the presence of disease associated to an impacted 3M, whether symptomatic or not. In contrast, extraction is not indicated in the absence of infection or other associated disease conditions. Key words:Third molar, periodontal disease, periodontitis, pericoronitis, dental caries, occlusal caries, mandibular cysts, osteomyelitis, odontogenic tumor.

Radiological risk indicators for persistent postoperative morbidity after third molar removal

OBJECTIVES

Although panoramic radiographs are extensively studied for diagnosis and preoperative planning in third molar surgery, research on the predictive value of this radiographic information regarding the postoperative recovery of patients remains underexploited. This prospective cohort study aimed to assess the potential relationship between radiologic risk indicators and persistent postoperative morbidity, in 1009 patients undergoing 2825 third molar extractions in context of the M3BE study.

METHODS

Two observers evaluated ten radiographic parameters: vertical and horizontal eruption status, third molar orientation, surgical difficulty, nerve relation, maxillary sinus relation, presence of periapical and pericoronal radiolucencies, caries, and third or second molar resorption. Patients' postoperative recovery was recorded 3 and 10 days after surgery. Univariate logistic regression was performed to assess potential associations between radiographic risk indicators and persistent postoperative morbidity.

RESULTS

Deep impactions were significantly associated with the persistence of postoperative pain, trismus and swelling until 10 days after surgery, prolonged need for pain medication, and the inability to resume daily activities and work/studies. Pericoronal radiolucencies and resorption were significantly associated with persistent morbidity and a longer recovery time, whereas caries and periapical lesions were linked to a shorter recovery time.

CONCLUSION

Based on the results of this study, clinicians may better inform patients at risk for persistent postoperative discomfort according to what was preoperatively diagnosed on the panoramic radiograph.

CLINICAL RELEVANCE

Preoperative panoramic radiographs contain information about patients at risk of prolonged recovery after third molar removal. Several risk indicators for persistent postoperative morbidity were identified.

Evaluation of Mandibular Third Molar Region in a Turkish Population Using Cone-Beam Computed Tomography

OBJECTIVES

To evaluate impacted mandibular third molar tooth region and obtain linear measurements using CBCT images and to assess the relationship between the impacted third molar and the mandibular canal.

METHODS

CBCT scans of 351 patients (208 females, 143 males) were assessed. Age, gender, and impaction site were recorded for each patient. The relationship of third molars with the vertical axis of second molars, 2nd molar resorption and the relationship between third molar apices and the mandibular canal were assessed. In addition, the distance between ramus and second molar, mesiodistal width of the third molar, the angle between third molar and second molar, and width of the third molar capsule were measured. Binary Logistic Regression, Chi-Square Test, and General Linear Model were used for statistical analysis.

RESULTS

The highest percentage of impaction was found for mesioangular followed by transversal and vertical. The transversal impacted third molars revealed a significant association with adjacent second molar root resorption (p<0.001). There was a statistical significance between the second molar resorption and distance between ramus and second molar (p<0.001). The mesioangular impacted third molars revealed significant relation with the mandibular canal (p<0.05). The most frequent variation found was the dental canal followed by the retromolar canal. In general, higher measurement values were obtained for men when compared to women (p<0.05).

CONCLUSION

CBCT assessment of the third molar region provided useful information regarding impacted mandibular third molar surgery operations.

Where is the 'wisdom' in wisdom tooth surgery? A review of national and international third molar surgery guidelines

The objective of this narrative review was to identify and evaluate published international guidelines on mandibular third molars (M3M) and to assess their clinical scope and the validity of the recommendations. The search strategy used data obtained from a variety of sources including MEDLINE, national regulatory bodies, national dental and surgical colleges and associations, and military medical departments. Adherence to clinical guideline development was investigated using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation). Sixteen guidelines pertaining to M3M were included in this review. The guidelines produced by the Faculty of Dental Surgery of the Royal College of Surgeons of England (FDS RCS) and Scottish Intercollegiate Guidelines Network (SIGN) were recommended as meeting the criteria for use. Seven other guidelines were recommended but required modifications. The AGREE II instrument provides an excellent framework for guideline assessment. Unfortunately, very few guidelines scored highly across all domains and therefore were not believed to be of high quality. Due to the significant lack of structure and variable standards in guideline development, the conclusions and recommendations of these guidelines are compromised. There is a need for organizations involved in developing M3M guidelines to update guidance periodically in order to ensure that the information available to clinicians and patients is accurate and relevant to clinical practice.

Prophylactic removal of impacted mandibular third molars: a systematic review and economic evaluation

BACKGROUND

Impacted third molars are third molars that are blocked, by soft tissue or bone, from fully erupting through the gum. This can cause pain and disease. The treatment options for people with impacted third molars are removal or retention with standard care. If there are pathological changes, the current National Institute for Health and Care Excellence guidance states that the impacted third molar should be removed.

OBJECTIVE

The objective of this study was to appraise the clinical effectiveness and cost-effectiveness of the prophylactic removal of impacted mandibular third molars compared with retention of, and standard care for, impacted third molars.

METHODS

Five electronic databases were searched (1999 to 29 April 2016) to identify relevant evidence [The Cochrane Library (searched 4 April 2016 and 29 April 2016), MEDLINE (searched 4 April 2016 and 29 April 2016), EMBASE (searched 4 April 2016 and 29 April 2016), EconLit (searched 4 April 2016 and 29 April 2016) and NHS Economic Evaluation Database (searched 4 April 2016)]. Studies that compared the prophylactic removal of impacted mandibular third molars with retention and standard care or studies that assessed the outcomes from either approach were included. The clinical outcomes considered were pathology associated with retention, post-operative complications following extraction and adverse effects of treatment. Cost-effectiveness outcomes included UK costs and health-related quality-of-life measures. In addition, the assessment group constructed a de novo economic model to compare the cost-effectiveness of a prophylactic removal strategy with that of retention and standard care.

RESULTS

The clinical review identified four cohort studies and nine systematic reviews. In the two studies that reported on surgical complications, no serious complications were reported. Pathological changes due to retention of asymptomatic impacted mandibular third molars were reported by three studies. In these studies, the extraction rate for retained impacted mandibular third molars varied from 5.5% to 31.4%; this variation can be explained by the differing follow-up periods (i.e. 1 and 5 years). The findings from this review are consistent with the findings from previous systematic reviews. Two published cost-effectiveness studies were identified. The authors of both studies concluded that, to their knowledge, there is currently no economic evidence to support the prophylactic removal of impacted mandibular third molars. The results generated by the assessment group's lifetime economic model indicated that the incremental cost-effectiveness ratio per quality-adjusted life-year gained for the comparison of a prophylactic removal strategy with a retention and standard care strategy is £11,741 for people aged 20 years with asymptomatic impacted mandibular third molars. The incremental cost per person associated with prophylactic extraction is £55.71, with an incremental quality-adjusted life-year gain of 0.005 per person. The base-case incremental cost-effectiveness ratio per quality-adjusted life-year gained was found to be robust when a range of sensitivity and scenario analyses were carried out.

LIMITATIONS

Limitations of the study included that no head-to-head trials comparing the effectiveness of prophylactic removal of impacted mandibular third molars with retention and standard care were identified with the assessment group model that was built on observational data. Utility data on impacted mandibular third molars and their symptoms are lacking.

CONCLUSIONS

The evidence comparing the prophylactic removal of impacted mandibular third molars with retention and standard care is very limited. However, the results from an exploratory assessment group model, which uses available evidence on symptom development and extraction rates of retained impacted mandibular third molars, suggest that prophylactic removal may be the more cost-effective strategy.

FUTURE WORK

Effectiveness evidence is lacking. Head-to-head trials comparing the prophylactic removal of trouble-free impacted mandibular third molars with retention and watchful waiting are required. If this is not possible, routine clinical data, using common definitions and outcome reporting methods, should be collected.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016037776.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 30. See the NIHR Journals Library website for further project information.

Collaboration with an infection control team promoted appropriate antibiotic use for third molar extraction at a Japanese hospital

Oral antibiotic therapy is routinely administered when a third molar (M3) is extracted to prevent infectious complications after surgery. Oral third-generation cephalosporins are frequently used after M3 extraction in Japan but at the expense of an increased risk of antimicrobial resistance. Therefore, the infection control team (ICT) at our institution recommended a reduction in use of these agents after M3 extraction. In this study, we compared the types of antibiotic agents prescribed for patients undergoing M3 extraction before and after this recommendation. We investigated the relationship between type of antibiotic used and the likelihood of infectious complications as well as cost savings in patients who underwent M3 extraction in the 6 months before and after the ICT recommendation in July 2018. There was a marked reduction in use of oral third-generation cephalosporins after M3 extraction (P < 0.0001) and increased use of oral penicillins and first-generation cephalosporins after the ICT recommendation. Moreover, surgical site infection (SSIs) were significantly less common after the ICT recommendation (P = 0.0099); however, the SSI rate was higher in patients who received a third-generation cephalosporin than in those who received penicillin (8.8% vs 0.5%). There was also a significant saving in per-patient antibiotic costs after the ICT recommendation (269.5 ± 282.0 JPY vs 454.7 ± 376.6 JPY; P < 0.0001). These findings suggest that collaboration with an ICT promotes appropriate antibiotic use, decreases the risk of an SSI, and improves the cost-benefit ratio in patients undergoing M3 extraction.

Osteomyelitis of the Mandible Caused by Late Fracture following Third Molar Extraction

The common postoperative complications of the extraction of third molars are frequently reported; however, reports about osteomyelitis of the mandible caused by late fracture following third molar extraction are rare. Here, we report a case of osteomyelitis of the mandible caused by late fracture following third molar extraction. A 38-year-old Japanese man was referred to the surgery department with chief complaints of dull pain and swelling in the right masseteric region and paresthesia of his lower lip and mental region in March 2018. A family dentist removed his lower third molar in the right side in January 2018. When the patient was chewing an innards stew 23 days after the procedure, he heard a cracking sound from the right mandible. Thus, we diagnosed the patient as having osteomyelitis of the mandible caused by late fracture following third molar extraction and performed sequestrectomy and curettage under general anesthesia in April 2018. In conclusion, it is necessary to recognize the possibility that late fracture following third molar extraction can cause osteomyelitis. Furthermore, once osteomyelitis of the mandible caused by late fracture occurred, early and appropriate treatment is necessary because the osteomyelitis may progress rapidly and in some cases may result in pathological fracture.

Is prophylactic removal of impacted mandibular third molar justified in all patients? A prospective clinical study of patients 50 years and above

BACKGROUND

The prophylactic extraction of asymptomatic impacted mandibular third molar is a contentious issue in dental practice.

OBJECTIVE

To evaluate symptomatic impacted mandibular third molars in patients 50 years and above, and determine the burden of the impaction on the adjacent second molar.

METHODS

This was a prospective clinical study over a three-year period. The diagnosis of impacted mandibular third molar and their associated pathology was made by clinical and radiological examination. The data obtained were age, sex, type of impaction, reason for surgical extraction, and the clinical condition of the adjacent second molar.

RESULTS

Patients 50 years and above were 33.4%, and those with impaction 22.8%, while the symptomatic cases were in 18.4% patients. The age of the patients ranged from 52 to 84 years with male: female ratio, 2.3:1. In all the asymptomatic impactions, the adjacent second molars were disease-free, whereas 73.6% of the adjacent second molar related to symptomatic cases were asymptomatic (P=0.001).

CONCLUSION

This study showed that 15.9% of impactions in 18.4% of patients were symptomatic and required surgical extraction, whereas the burden of impaction on the adjacent second molar was 26.4%, and these required only preventive and restorative treatments.

Computer-Aided Design/Computer-Aided Manufacturing Cutting Guides for Odontectomy of Deeply Impacted Mandibular Third Molars

AIM:

To evaluate a new technique for surgical removal of deeply impacted mandibular third molars (DIMTM), using computer-guided cutting guide to maintain inferior alveolar nerve (IAN) integrity and the covering buccal bone.

PATIENTS AND METHODS:

Eighteen cases indicated for removal of DIMTM. Cone-beam Computed Tomography (CBCTs) used to determine the tooth’s relation to the IAN. Computer-guided software used for fabrication of surgical cutting guide stent to expose the impacted tooth and repositioning of bone after odontectomy without fixation. Clinical assessment included a neurosensory deficit of IAN, pain using a visual analogue scale (VAS), facial swelling, and maximal mouth opening (MMO). CBCTs were taken immediately and six months postoperatively to evaluate position and healing of bone.

RESULTS:

None of the patients showed a permanent neurological deficit of IAN while all patients showed normal parameters of pain, facial swelling and MMO.

CONCLUSION:

this technique has shown the accurate determination of the bony window cuts with subsequent preservation of IAN and external oblique ridge.

Comparison of the efficacy of amoxicillin-clavulanic acid with metronidazole to azithromycin with metronidazole after surgical removal of impacted lower third molar to prevent infection

Objectives

The goal of the study was to investigate the clinical effects of amoxicillin-clavulanic acid (500+125 mg) with metronidazole 400 mg administered three times daily (Group I) versus azithromycin 500 mg administered once daily and with metronidazole 400 mg three times daily (Group II) for the prevention of postoperative infection following mandibular third molar surgical removal.

Materials and Methods

The study design was a single-center prospective study. Patients who reported to the Department of Oral and Maxillofacial Surgery between February 2015 and January 2017 for removal of mandibular third molar were screened, and 108 patients were chosen. One surgeon carried out all procedures. Patients were prescribed antibiotics until the two groups contained a similar number of cases.

Results

Our data showed that Group II had fewer incidences of surgical site infection, but with no statistical significance.

Conclusion

Although both treatments are used routinely after removal of the mandibular third molar, neither is significantly better than the other.

Comparisons of the Computed Tomographic Scan and Panoramic Radiography Before Mandibular Third Molar Extraction Surgery

BACKGROUND Mandibular third molar extraction surgery has a postoperative complication of hypoesthesia of the lower lip and/or chin. The objective of the study was to determine if preoperative radiographic examination by panoramic radiography and computed tomography (CT) scan can predict postoperative complications of mandibular third molar extraction surgery. MATERIAL AND METHODS In total, 479 patients who had mandibular third molar extraction surgery were included in this cross-sectional study. Patients had panoramic radiographies and CT scans to determine the relationship of the tooth, the canal, and the buccolingual position. Inferior alveolar nerve sensory impairment was detected using a two-point discrimination method. Wilcoxon test and Tukey's test were used to compare diagnostic modalities at a 99% confidence level. RESULTS Inferior alveolar nerve was more successfully quantified by CT scan compared to panoramic radiography (p<0.0001, q=8.062). Orthopantomography was better than the CT scan in detecting a close relationship of the tooth and the canal (p<0.0001, q=25.609), but the CT scan was better in detecting the buccolingual position of the teeth (p<0.0001, q=36.757). The age of patients (p<0.0001, q=36.757), postoperative bleeding (p<0.0001, q=15.981), and experience of the surgeon (p<0.0001, q=10.99) had an affected on inferior alveolar nerve sensory impairment. CONCLUSIONS Preoperative panoramic radiography, CT scan, age, the experience of the surgeon, and postoperative bleeding can predict postoperative complications for extraction of a mandibular third molar.

Reliability and validity of measuring scale for postoperative complications in third molar surgery

Background

Third molar removal surgery is the most frequently performed surgery in the oral and maxillofacial field with a wide range of items in the quantification of postoperative complications. For their measure, in 2014 a previous scale design was presented. The aim of this study was to determine the reliability and validity of a scale designed to measure and quantify postoperative complications in third molar surgery (TMS).

Methods

A cross-sectional study of a measurement model was designed. Sixty-two patients (mean age 20.5 ± 6.6 years; 36 women) underwent TMS in three Chilean hospitals. In the postoperative check-up on the 7th day, a maxillofacial surgeon and a surgical resident performed independent postoperative assessments, applying the scale. A confirmatory factor analysis was conducted to obtain validity, internal consistency, interobserver reliability and a score to categorize the severity of complications using structural equation model analysis.

Results

Nine patients (14.5%) had complications. The scale was defined by two components: “Secondary complication” and “Infection” (Cronbach’s alpha 0.71; Interobserver reliability 87.7%) and three categories of postoperative complication: “without or mild”, “moderate” and “severe”.

Conclusion

This study presents a reliability and validity scale called “Surgical complication assessment scale in TMS”.

Efficacy of different methods used for dry socket prevention and risk factor analysis: A systematic review

BACKGROUND

Dry socket is one of the most common complications that develops after the extraction of a permanent tooth, and its prevention is more effective than its treatment.

OBJECTIVES

Analyze the efficacy of different methods used in preventing dry socket in order to decrease its incidence after tooth extraction.

MATERIAL AND METHODS

A Cochrane and PubMed-MEDLINE database search was conducted with the search terms "dry socket", "prevention", "risk factors", "alveolar osteitis" and "fibrynolitic alveolitis", both individually and using the Boolean operator "AND". The inclusion criteria were: clinical studies including at least 30 patients, articles published from 2005 to 2015 and written in English. The exclusion criteria were case reports and nonhuman studies.

RESULTS

30 publications were selected from a total of 250. Six of the 30 were excluded after reading the full text. The final review included 24 articles: 9 prospective studies, 2 retrospective studies and 13 clinical trials. They were stratified according to their level of scientific evidence using SIGN criteria (Scottish Intercollegiate Guidelines Network).

CONCLUSIONS

All treatments included in the review were aimed at decreasing the incidence of dry socket. Locally administering chlorhexidine or applying platelet-rich plasma reduces the likelihood of developing this complication. Antibiotic prescription does not avoid postoperative complications after lower third molar surgery. With regard to risk factors, all of the articles selected suggest that patient age, history of previous infection and the difficulty of the extraction are the most common predisposing factors for developing dry socket. There is no consensus that smoking, gender or menstrual cycles are risk factors. Taking the scientific quality of the articles evaluated into account, a level B recommendation has been given for the proposed-procedures in the prevention of dry socket.

Postoperative socket irrigation with drinking tap water reduces the risk of inflammatory complications following surgical removal of third molars: a multicenter randomized trial

Objectives

The primary aim of the present study was to evaluate the effectiveness of postoperative irrigation of the socket with drinking tap water on inflammatory complications following lower third molar removal.

Material and methods

A multicenter randomized controlled trial was carried out from June 2013 to June 2014. In one arm of the study, patients were instructed to irrigate the tooth socket and surgical site with a Monoject® Curved 412 Tip Syringe (Tyco/healthcare-Kendall, Mansfield, MA, USA) with tap water. In a second arm of the study, the standard postoperative instructions did not include irrigation instructions. The incidences of alveolar osteitis and wound infection were recorded for each group and analyzed by the Fisher’s exact test.

Results

A total of 280 patients with 333 mandibular third molars were analyzed. According to the intention-to-treat (ITT) analysis, inflammatory complications occurred in 18 cases in the Monoject® group (11.4 %) compared to 34 cases (19.1 %) in the control group (p = 0.04). These complications were associated with significant worse outcomes regarding quality of life, pain, and trismus and caused significantly more missed days of work or study. Female gender, age >26, bone removal, deep impacted third molars, less experienced surgeons, and a high amount of debris at the surgical site were also identified as risk factors for developing inflammatory complications following lower third molar removal.

Conclusion

Irrigation of the surgical site with drinking tap water using a curved syringe following removal of third molars is effective in reducing the risk of inflammatory complications.

Clinical relevance

Water is a very accessible, cost-effective irrigant without side effects and the results from this study have proven that it can be used to reduce the risk of inflammatory complications and associated morbidity following lower third molar removal.

The Assessment of Oral Microflora Exposed to 3% Ethanolic Extract of Brazilian Green Propolis Preparation Used for Hygiene Maintenance following Minor Oral Surgeries

The aim of this study was to investigate the influence of a topically administered hygienic preparation containing a 3% ethanolic extract of Brazilian green propolis (EEP-B) on oral microflora spectrum changes in a group of patients who underwent common oral surgery procedures. Two gel samples were compared: the tested gel containing an active ingredient, that is, a 3% EEP-B (gel GA), and a placebo as the negative control (gel GC). The collection of microbiological material included 14 patients requiring surgical extraction of wisdom molars and short endosseous implant installation. Clinical examinations were carried out as follow-up, that is, baseline and after 5-6 weeks' time. During the first and subsequent assessment, swabs were taken from the mucosal surface. The number of microorganism species was found to have increased following the application of GC gel over the period of 5-6 weeks. This mainly affected Gram-positive rods and bacilli as well as Gram-negative rods. Application of the GA gel enriched with 3% EEP-B caused a profound reduction in the amount of Neisseria spp. and Bifidobacterium spp. strains. Elimination of seven species of microorganisms was observed: Streptococcus acidominimus, Streptococcus oralis, Staphylococcus epidermidis, Veillonella parvula, Bifidobacterium breve, Bifidobacterium longum, and Lactobacillus acidophilus.

Complication rates in patients using absorbable collagen sponges in third molar extraction sockets: a retrospective study

OBJECTIVES

The purpose of this study is to retrospectively evaluate the postoperative complication rates for absorbable type-I collagen sponge (Ateloplug; Bioland) use in third molar extraction.

MATERIALS AND METHODS

From January to August 2013, 2,697 total patients undergoing third molar extraction and type-I collagen sponge application in the Department of Oral and Maxillofacial Surgery at Yonsei University Dental Hospital (1,163 patients) and Dong-A University Hospital (1,534 patients) were evaluated in a retrospective study using their operation and medical records.

RESULTS

A total of 3,869 third molars in 2,697 patients were extracted and the extraction sockets packed with type-I collagen sponges to prevent postoperative complications. As a result, the overall complication rate was 4.52%, with 3.00% experiencing surgical site infection (SSI), 1.14% showing alveolar osteitis, and 0.39% experiencing hematoma. Of the total number of complications, SSI accounted for more than a half at 66.29%.

CONCLUSION

Compared to previous studies, this study showed a relatively low incidence of complications. The use of type-I collagen sponges is recommended for the prevention of complications after third molar extraction.

Qualidade de vida de pacientes submetidos à exodontia de terceiros molares

INTRODUÇÃO: A remoção dos terceiros molares pode causar transtornos e prejuízos à qualidade de vida. OBJETIVO: Avaliar a qualidade de vida de pacientes submetidos à exodontia de terceiros molares, discutindo os eventos mais comumente observados. MATERIAL E MÉTODO: Sessenta pacientes de uma Clínica Privada de Cirurgia, da cidade de João Pessoa-PB, foram submetidos à exodontia de terceiros molares, pelo mesmo operador e em condições semelhantes. Os dados foram coletados em duas etapas: a primeira foi realizada no dia do procedimento, quando foram anotados os dados do paciente, assim como as informações relacionadas à cirurgia. A segunda etapa foi realizada sete dias após o procedimento, quando os pacientes responderam o formulário acerca da qualidade de vida durante o pós-operatório. RESULTADO: 71,4% dos pacientes submetidos a Osteotomia e Odontossecção mantiveram suas atividades normais, e 28,6% não mantiveram. No entanto, quanto aos pacientes não submetidos às técnicas, 40,9% mantiveram suas atividades normais e 59,1% não mantiveram. De acordo com a classificação de Pell & Gregory, percebeu-se que 71,4% dos pacientes Classe 3 mantiveram suas atividades sociais normalmente, enquanto 60% dos pacientes Posição C não as mantiveram. Dos pacientes que se isolaram socialmente e foram submetidos às técnicas, 71,4% relataram a dor como o principal motivo, e 100% dos pacientes Classe 3 e 80% dos pacientes Posição C optaram pela mesma resposta. CONCLUSÃO: Os resultados indicam que as técnicas empregadas no transoperatório não interferem na qualidade de vida do paciente durante o pós-operatório e a posição tem maior influência do que a classe, no que se refere ao desenvolvimento normal das atividades sociais.

What is the risk of future extraction of asymptomatic third molars? A systematic review

PURPOSE

The purpose of our report was to determine clinically whether young adults who elect to retain their asymptomatic third molars (M3s) have a risk of undergoing 1 or more M3 extractions in the future.

MATERIALS AND METHODS

To address our clinical question, we designed and implemented a systematic review. The studies included in the present review were prospective, had a sample size of 50 subjects or more with at least 1 asymptomatic M3, and had at least 12 months of follow-up data available. The primary study variables were the follow-up duration (in years) and the number of M3s extracted by the end of the follow-up period or the number of subjects who required at least one M3 extraction. The annual and cumulative incidence rates of M3 removal were estimated.

RESULTS

Seven studies met the inclusion criteria. The samples sizes ranged from 70 to 821 subjects, and the follow-up period ranged from 1 to 18 years. The mean incidence rate for M3 extraction of previously asymptomatic M3s was 3.0% annually (range 1 to 9%). The cumulative incidence rate for M3 removal ranged from 5% at 1 year to 64% at 18 years. The reasons for extraction were caries, periodontal disease, and other inflammatory conditions.

CONCLUSIONS

The cumulative risk of M3 extraction for young adults with asymptomatic M3s is sufficiently high to warrant its consideration when reviewing the risks and benefits of M3 retention as a management strategy.

Mandibular third molar impaction: review of literature and a proposal of a classification

Objectives

The purpose of present article was to review impacted mandibular third molar aetiology, clinical anatomy, radiologic examination, surgical treatment and possible complications, as well as to create new mandibular third molar impaction and extraction difficulty degree classification based on anatomical and radiologic findings and literature review results.

Material and Methods

Literature was selected through a search of PubMed, Embase and Cochrane electronic databases. The keywords used for search were mandibular third molar, impacted mandibular third molar, inferior alveolar nerve injury third molar, lingual nerve injury third molar. The search was restricted to English language articles, published from 1976 to April 2013. Additionally, a manual search in the major anatomy and oral surgery journals and books was performed. The publications there selected by including clinical and human anatomy studies.

Results

In total 75 literature sources were obtained and reviewed. Impacted mandibular third molar aetiology, clinical anatomy, radiographic examination, surgical extraction of and possible complications, classifications and risk factors were discussed. New mandibular third molar impaction and extraction difficulty degree classification based on anatomical and radiologic findings and literature review results was proposed.

Conclusions

The classification proposed here based on anatomical and radiological impacted mandibular third molar features is promising to be a helpful tool for impacted tooth assessment as well as for planning for surgical operation. Further clinical studies should be conducted for new classification validation and reliability evaluation.

A single dose of amoxicillin and dexamethasone for prevention of postoperative complications in third molar surgery: a randomized, double-blind, placebo controlled clinical trial

Background

The aim of this study was to assess the efficacy of a single prophylactic dose of amoxicillin and/or dexamethasone in preventing postoperative complications (PC) after a surgical removal of a single mandibular third molar (M3).

Methods

This study is a randomized, placebo controlled clinical trial. Four groups were included: Group 1 (G1) included a prophylactic dose of 2 g of amoxicillin and 8 mg of dexamethasone; Group 2 (G2) included a prophylactic dose of 2 g of amoxicillin and 8 mg of placebo; Group 3 (G3) included a prophylactic dose of 8 mg of dexamethasone and 2 g of placebo and; Group 4 (G4) placebo.

Results

Fifty patients were included. It was observed one case of alveolar infection (2%) and two of alveolar osteitis (4%) resulting in three PC (6%). No statistical differences were observed between therapeutic groups for development of PC, trismus, pain and edema. The use of antibiotics showed an absolute risk reduction (ARR) for PC development of 3.52% and the number needed to treat (NNT) was 29.

Conclusion

Prophylactic antibiotics and corticoid in a single dose regimen did not bring any benefit on M3 surgeries.

Logistic regression analysis of risk factors for the development of alveolar osteitis

PURPOSE

To assess risk factors for alveolar osteitis.

MATERIALS AND METHODS

A prospective nested case-control study was conducted in an urban community dental clinic in Valdivia, Chile. A cohort of 1,355 patients who underwent dental extractions was included. Eight predictor variables (risk factors), namely patient gender, hygiene, tooth location, previous surgical site infection, traumatic extraction, systemic diseases, alcohol consumption, and tobacco use, were considered in a risk factor model. A binary regression logistic analysis was performed to determine significant associations.

RESULTS

In total 1,302 participants completed the follow-up. Eighty incident case patients with alveolar osteitis and 80 matched control patients were included. A statistically significant association was found between traumatic extraction (odds ratio [OR], 13.1; 95% confidence interval [CI], 5.4 to 31.7), tobacco smoking after extraction (OR, 3.5; 95% CI, 1.3 to 9.0), previous surgical site infection (OR, 3.3; 95% CI, 1.4 to 7.7), and the development of alveolar osteitis.

CONCLUSIONS

Previous surgical site infection, traumatic extraction, and tobacco smoking are associated with an increased risk of alveolar osteitis.

After dentoalveolar surgery, most patients are satisfied with telephone follow-up

PURPOSE

To estimate patient satisfaction with telephone follow-up and compare the frequencies of postoperative complications between patients undergoing telephone and those undergoing clinical follow-up after ambulatory office-based dentoalveolar procedures.

MATERIALS AND METHODS

Using a retrospective study design, the investigators enrolled a cohort of subjects who had had at least 1 tooth extracted during a 2-year period. The primary study variable was subject self-report of satisfaction with the telephone follow-up. For additional analyses, the predictor variable was follow-up type grouped as telephone versus clinical. The outcome variable was postoperative complications. To measure the relationships between the follow-up type and postoperative complications, bivariate and multiple logistic regression statistics were computed. P ≤ .05 was considered significant.

RESULTS

The sample was composed of 364 subjects, of whom 155 (42.6%) had received telephone follow-up. The sample's mean age was 28.6 ± 11.7 years, included 220 females (60.4%), and had had an average of 3.4 ± 2.1 teeth removed. The self-reported patient satisfaction rate with telephone follow-up was 95.9%. The subjects who experienced postoperative complications were 90% less likely to be satisfied relative to those without complications (P = .04). The overall complication frequency was 19.2%, with telephone follow-up subjects having a lower complication frequency (12.9%) than the clinical follow-up subjects (23.4%) (P < .01). After adjusting for differences between the 2 samples, no significant difference was found in the complication frequencies according to the method of follow-up (P = .7).

CONCLUSION

Patient satisfaction with telephone follow-up was high. The subjects scheduled for telephone follow-up had a complication rate that was similar to that of the clinical follow-up subjects.

Prognostic factors affecting the duration of disability after third molar removal

PURPOSE

The purposes of this investigation were 1) to estimate the duration of disability after third molar removal and 2) to identify factors associated with prolonged recovery.

MATERIALS AND METHODS

This was a prospective cohort study composed of subjects enrolled in the American Association of Oral and Maxillofacial Surgeons Age-Related Third Molar Study. The predictor variables were grouped as follows: demographic, health status, anatomic, pathologic, medications, and complications. The outcome variable was the duration of postoperative disability measured as the number of days the subject reported inability to perform normal daily activities after third molar removal. Bivariate and multiple linear regression analyses were used. The level of statistical significance was P < .05.

RESULTS

The study sample included 4,004 subjects who had 8,748 third molars removed. The mean duration of postoperative disability was 1.4 ± 1.8 days (range, 0-26; median, 1 day). In the multiple linear regression model, age, female gender, number of third molars removed, mandibular third molar removal, full-bony impaction, sum of antibiotics or pain medications, and complications were associated with prolonged recovery (P < .05). Erupted third molars, periodontal disease or other preoperative pathology, and use of chlorhexidine were associated with earlier return to normal daily activities (P < .05).

CONCLUSION

The study results suggest that third molar removal is associated with a mean delay in returning to normal activities of less than 2 days. Several factors were statistically associated with time to return to normal activities.