Third Molar Complications in the Elderly—A Matched-Pairs Analysis

Are There Differences in the Causes and Complications of Mandibular Third Molar Extraction in Older Patients Compared to Younger Patients?

BACKGROUND

Although most impacted third molars (ITMs) are extracted in the teens and early 20s, some undergo extractions after their 40s. It is unclear whether the reasons for extraction, the degree of impaction, and complications differ in patients in an older age group compared with a younger age group.

PURPOSE

The purpose of this study was to measure the association between age and 1) reason for extraction and 2) postoperative complications.

STUDY DESIGN, SETTING, SAMPLE

This was a retrospective cohort study of patients who had undergone surgical extraction of at least one mandibular ITM at a single institution. We excluded 1) age under 20 years, 2) follow-up period of less than 1 week, and 3) tooth extraction under general anesthesia.

PREDICTOR VARIABLE

The primary predictor variable was age, classified into 3 groups (20s:20-29; 30s:30-39; over 40s: 40 and greater).

MAIN OUTCOME VARIABLE(S)

The primary outcome variables were the reason for extraction (prophylactic or symptomatic) and the presence of complications. The secondary outcome variable was type of complication (postoperative infection, dry socket, neurosensory disturbance, presenting pain over 1 month, retained root requiring secondary treatment).

COVARIATES

The covariates were sex, laterality of ITM, and difficulty of extraction as measured by the difficulty index, a measure based on depth, orientation, and ramus relationship/space available, with a higher score indicating greater difficulty.

ANALYSES

χ2 test was performed to analyze the association of categorical outcome variables and covariates. Level of statistical significance was set at P < .05.

RESULTS

Of a total of 831 eligible subjects, there were 555 (66.8%), 159 (19.1%), and 117 (14.1%) in the 20s, 30s, and over 40s age groups, respectively. The percentage of symptomatic extraction of ITM was significantly higher in the over-40 age group compared with the 20s group (92.3 vs 69.4%, (P < .001). Complication rate also significantly differed between over 40s group and the 20s group (7.7 vs 1.8%, P < .001). Difficulty index and indications for ITM extraction were significantly different between groups (P < .001).

CONCLUSION AND RELEVANCE

Symptoms, difficulty, and complications related to ITM increase at over 40 years of age. This should be taken into consideration during the joint clinical decision-making process with patients with ITM.

A Retrospective Analysis of Postoperative Abscess Formation Following Wisdom Tooth Removal and Their Clinical Condition and Localization

AIM

As a common procedure in oral surgery, the removal of wisdom teeth (3M) is associated with a variety of postoperative complications. This study reports of deep tissue abscesses after the removal of 3M in correlation to several factors.

MATERIALS AND METHODS

Patients between 2012 and 2017 with removed 3M were retrospectively evaluated in terms of clinical condition and localization and thus assigned tog A (removal of asymptomatic 3M) or group B (removal of symptomatic 3M). Moreover, they were analyzed in terms of abscesses after the removal and correlation with various parameters: localization of the abscess, general diseases, perioperative antibiotic treatment, number of days from removal of the tooth to abscess formation, and postoperative complications after primary abscess incision.

RESULTS

About 82 patients (male n = 44, female n = 38) were included, with 88 wisdom teeth removed and postoperative abscesses. Postoperative abscesses occurred more frequently in group B (n = 53) with n = 29 in IIB localization, without a significant correlation. Patients in this group were older, and there were more surgical abscess incisions needed, despite a longer treatment with oral and intravenous antibiosis that correlated with neurologic diseases and age. Younger patients reported significantly more pain.

CONCLUSIONS

Detection of potential 3M pathologies at an early and asymptomatic stage is essential to avoid postoperative complications following 3M removal. Additional prospective studies are necessary to develop corresponding guidelines.

CLINICAL SIGNIFICANCE

Wisdom tooth extraction is the most common operation in oral surgery, and therefore, adequate risk evaluation is still required.

Diagnostic Aspects of an Included Third Molar in an 88-Year-Old Patient: A Case Report and Literature Review

Included third molars in elderly patients are quite rare in dental practice, and therefore easily misdiagnosed, because these teeth are usually extracted in youth. Additional challenges to correctly diagnosing such a dental condition, and its associated complications, arise from frequent co-morbidities in elderly patients, and from difficult communication with the patient. We report a case of an 88-year-old female patient, who presented in the dental emergency room complaining of a discomfort caused by the sharp edges of her lower incisors, and requesting their extraction; the final diagnosis, of suppurated pericoronitis at tooth 48, was concluded based on the clinical elements and X-ray examination.

Third molar extraction in middle-aged and elderly patient

Extraction of impacted third molars is a routine procedure performed by oral and maxillofacial surgeons. However, extractions in middle-aged or elderly individuals are not easy, and there are several factors that need to be considered. These factors include decreased healing potential and the risk of complications increasing with age. In addition, third molars can often be fully or deeply impacted in middle-aged individuals, and pathologic changes, such as cysts, caries, or periodontitis of the adjacent second molar, can develop. Furthermore, the rate of ankylosis and systemic disease increases after middle age. It is considered that these factors acting alone or in combination increase the difficulty of extraction.

To prophylactically extract or not to extract partially erupted mesio-angularly impacted lower third molars?

Introduction Prophylactic removal of mesio-angularly impacted mandibular third molars (MAIM3Ms) has been discouraged by the National Institute for Health and Care Excellence in 2000. Consequently, partially erupted MAIM3Ms are retained for longer and only extracted if complications arise. The debate whether to extract prophylactically or to monitor these teeth is ongoing.Pathologies associated with retained partially erupted MAIM3Ms Retaining third molars long into adulthood has been associated with an increased risk of distal cervical caries and external root resorption of the second molar, periodontal disease and pericoronitis, among other pathologies. Although watchful monitoring can help to identify these pathologies, their nature often leads not only to a poor prognosis for the third molar, but also for the second molar, which then requires costly and time-consuming restorative or even prosthodontic work.Considering prophylactic extractions While an individual risk assessment is paramount, prophylactic removal of partially erupted MAIM3Ms has been shown to have positive effects on oral health-related quality of life, to relieve the pressure on secondary care services and to be economically feasible for the NHS.Conclusion While long-term prospective cohort studies are necessary to put an end to the ongoing controversy, patients' needs and wishes should be at the forefront of the provision of care.

Evaluation of wound healing following surgical extractions using the IPR Scale

OBJECTIVE

To monitor wound healing following surgical extraction of wisdom teeth using the novel Inflammatory Proliferative Remodeling (IPR) Scale.

METHODS

A prospective study design was used. Participants included 94 otherwise healthy adult patients undergoing surgical extraction of a wisdom tooth at a tertiary medical centre from June 2018 to June 2019. The IPR Scale was completed by two resident surgeons in oral and maxillofacial surgery at three time points after the procedure, corresponding to the three phases of wound healing. Mean subscale and total scores were calculated. Patients graded their preoperative anxiety, intraoperative pain, and pain during follow-up on a 10 cm visual analog scale, and the findings were correlated with the IPR Scale scores.

RESULTS

Mean IPR total score (range 0-16) was excellent (14.43 ± 1.45). Mean scores by healing phase were as follows: inflammatory 6.35 ± 1.34 (range 0-8); proliferation, 4.56 ± 0.8 (range 0-5); remodeling, 2.83 ± 0.51 (range 0-3). There was a positive correlation between mean preoperative anxiety level (5.9 ± 3.6) and intraoperative pain perception (2.4 ± 2.4; P = 0.65) and a negative correlation between mean preoperative anxiety level and IPR Scale scores for each healing phase. Two cases were complicated by abscesses which resolved with treatment.

CONCLUSION

The IPR Scale is a promising tool for the effective evaluation of the wound healing process following wisdom tooth extractions. Relaxation methods and behavioural adaptation might help to lower patient anxiety and thereby improve oral wound healing.

Prophylactic Internal Fixation to Avoid Mandible Fracture With Third Molar Removal: Use of Computer-Assisted Surgery to Improve Clinical Outcomes

Although uncommon, iatrogenic fractures of the mandible may occur during the perioperative time period of a lower third molar removal. The case described used digital technology to apply prophylactic internal fixation before a lower third molar removal thought to be at high risk for a mandible fracture. A medical model of the patient's mandible was 3-dimensionally printed and used as a reference to prebend a titanium plate. Dynamic navigation, a form of computer-assisted surgery, was used during the surgery to accurately place the prebent titanium plate according to the corresponding position on the medical model.

Associations between aging and second molar diseases in patients having adjacent impacted third molar extraction

PURPOSE

There is limited evidence available regarding when the best time to extract impacted lower third molars (iLM3). Thus, the current study is aimed to examine the association between the age of patients during the time of extraction of their iLM3 and the sequelae of their adjacent second molar (LM2) in order to find a better time to remove iLM3.

METHODS

Retrospective cohort study was conducted with a total of 15,432 patients from ages 16-45 years old who had their first surgical extraction of iLM3. Statistical analysis was performed to evaluate variables in association with the sequalae of LM2. Adjusted odds ratios (AOR) were calculated to show the influence of the age of patients by multivariate regression model.

RESULTS

Patients who had iLM3 extraction over 22 years of age had a significantly higher risk of having LM2 pulpal disease (AOR: from 2.84 in 23-25 age to 11.58 in >35 age). Significantly higher risk of having LM2 periodontal conditions was found in individuals over 31 years of age (AOR: 1.47 in 31-35 age, 1.90 in >35 age), with prior periodontitis (AOR: 1.97) or complicated odontectomy (AOR: 1.43). The risk of LM2 being extracted due to an untreatable condition was highest in patients more than 35 years old (AOR: 14.38).

CONCLUSION

The age of patients having iLM3 extracted was independently associated with various LM2 sequelae. We suggest that patients can have their iLM3 extracted in their college/university age (19-22-year-old) to minimize complications on the adjacent LM2.

Impacts of non-impacted third molar removal on the periodontal condition of adjacent second molars

OBJECTIVE

The aim of this study was to determine how the removal of non-impacted third molars (N-M3s) affects the periodontal status of neighboring second molars (M2s).

SUBJECTS AND METHODS

The periodontal condition of M2s for which the neighboring N-M3s were removed (more than 6 months previously) and those with intact N-M3s was analyzed in a cross-sectional observation study. In an additional case series, periodontal changes in M2s in response to adjacent N-M3 removal were observed during a 6-month follow-up period.

RESULTS

A total of 457 patients with 1,301 M2s were enrolled in this cross-sectional observational study. Compared to M2s with neighboring N-M3s, M2s without neighboring N-M3s (teeth removed more than 6 months previously) exhibited a 0.27-mm reduction in the average pocket depth (PD) (p < .001) and a 0.38-fold reduced risk of at least one probing site with PD ≥5 mm (PD5+) (p < .001). Subsequently, a 41-case follow-up study showed that 6 months after neighboring N-M3 extraction, the PD of the M2s decreased by 0.31 mm (p < .001), while the incidence of PD5+ decreased by 21.9% when compared to the parameters detected before tooth extraction (p = .004).

CONCLUSIONS

Removing N-M3s was associated with an improved periodontal condition in neighboring M2s.

Prevalence of third molars determined by panoramic radiographs in a population-based survey of adult Finns

OBJECTIVES

The aim of the study was to examine the prevalence of third molars in panoramic radiographs in a population-based study of adults aged ≥30 years.

METHODS

Out of a sample of 8028 inhabitants of Finland, selected with two-staged stratified cluster-sampling method for the Health 2000 Survey, 5989 participated in clinical oral examination and panoramic radiography. Mean age was 52.5 years (SD 14.6; range 30-97 years). The following variables were included in the analysis: participant characteristics, clinical number of all teeth, and radiographic prevalence and characteristics of third molars. Statistics included chi-squared, Fisher's exact, and Kruskal-Wallis tests and SAS-SUDAAN calculations.

RESULTS

A total of 5912 third molars in 47.8% of the study population were recorded from panoramic radiographs. At least one impacted third molar was found in 21.9% of the study population. More than half (57.3%) of the remaining third molars were located in the mandible. A preponderance of participants with all third molars missing were observed in the oldest age group, women, those with lower education and those living in the countryside. Third molars or remnants thereof were observed radiographically in 3.9% of clinically edentulous study population.

CONCLUSIONS

The panoramic radiographs disclosed many remaining third molars in adult Finns aged ≥30 years. One-third of the third molars located impacted which may cause unexpected need for care.