An Observational Cohort Study on Delayed-Onset Infections after Mandibular Third-Molar Extractions

Prevalence of surgical site infections following extraction of impacted mandibular third molars: A systematic review and meta-analysis

Our research aims to assess the prevalence of surgical site infections (SSI) following impacted mandibular third molar extractions. Two independent reviewers conducted a comprehensive systematic literature search across Medline, Scopus and Cochrane Central databases. The pooled prevalence, accompanied by 95% confidence intervals (CI), was calculated. Quality assessments, outlier and influential analyses were performed. Our meta-analysis included seventeen eligible studies, encompassing a total of 37,585 impacted mandibular third molar extractions. The overall prevalence of SSI following impacted mandibular third molar extractions was estimated at 1.7% (95% CI 1%-2.6%), indicating considerable heterogeneity among the studies. No study was identified as critically influential. This study highlights the imperative for future well-constructed prospective and retrospective investigations to deepen our understanding of the etiological nuances and refine management approaches for this prevalent postoperative complication.

Histological and immunohistochemical characteristic of the gingival stroma in the portion of the third molars in children of various age

OBJECTIVE

Aim: To evaluate the state of the gingival stromal elements in the portion of the third molars requiring extraction of these teeth due to orthodontic indications considering the stage of tooth germ formation.

PATIENTS AND METHODS

Materials and Methods: The surgery to extract third molars due to orthodontic indications was performed on 95 children aged 11 to 18 years. The three groups of observation were isolated according to clinical-radiological signs: І (n=30) - children aged 11-13 years; ІІ (n=35) - children aged 13-16 years, and ІІІ (n=30) - children aged 16-18 years. During surgery, the samples of gums were taken from the adjacent areas for examination. The samples were fixed, dehydrated, paraffinized for further histological processing. Immunohistochemical methods were used according to the protocols supplied by a producer. In particular, by means of immunohistochemical method, Ki-67, CD-34 antigens and vimentin with primary antibodies against them were determined. The primary antibodies were visualized by the polymeric visualization system with diaminobenzidine giving a brown color to the places of location of the antigens examined. The data obtained were statistically processed.

RESULTS

Results: The results of the study showed that specific gravity of the vascular bed in the gingival papillary layer of children was the most variable. It ranges from (12,7±0,09) % at the stage of "D" root formation to (54,8±0,17) % at the "H" stage. Lower concentrations of CD-34 antigens and vimentin are found in the endotheliocytes of children aged 13-16 and 16-18 years, compared to the children aged 11-13 years (p<0,05). No changes were found in the specific volume of the blood vessels, CD-34 antigens and vimentin in the reticular gingival layer of children from the groups of observation.

CONCLUSION

Conclusions: Therefore, the conducted histological and immunohistochemical study of the connective gingival tissues in the portion of the third molars in children enables to draw a conclusion that in the process of formation of the root of this tooth a number of changes occur in the gingival stroma. They include an increase of the blood flow volume in the papillary gingival layer on the background of a decreased concentration of CD-34 genes and vimentin, a longer stage of development of the third molar root. The specific volume of the islets of neoangiogenesis of the papillary gingival layer is the largest in children aged 13-16 years.

Risk Factors for Delayed-Onset Infection after Mandibular Wisdom Tooth Extractions

Wisdom tooth extraction is one of the most commonly performed procedures by oral maxillofacial surgeons. Delayed-onset infection (DOI) is a rare complication of wisdom tooth extraction, and it occurs ~1–4 weeks after the extraction. In the present study, risk factors for DOI were investigated by retrospectively analyzing the cases of 1400 mandibular wisdom tooth extractions performed at Kagawa University Hospital from April 2015 to June 2022. Inclusion criteria were patients aged >15 years with a wisdom tooth extraction per our procedure. The exclusion criteria were patients with insufficient medical records, a >30-mm lesion around the wisdom tooth shown via X-ray, colonectomy, radiotherapy treatment of the mandible, the lack of panoramic images, and lesions other than a follicular cyst. The DOI incidence was 1.1% (16 cases), and univariate analyses revealed that the development of DOI was significantly associated with the Winter classification (p = 0.003), position (p = 0.003), hypertension (p = 0.011), and hemostatic agent use (p = 0.004). A multivariate logistic regression analysis demonstrated that position (OR = B for A, 7.75; p = 0.0163), hypertension (OR = 7.60, p = 0.013), and hemostatic agent use (OR = 6.87, p = 0.0022) were significantly associated with DOI development. Hypertension, hemostatic use, and position were found to be key factors for DOI; long-term observation may thus be necessary for patients with these risk factors.

Prevalence of and risk factors for postoperative complications after lower third molar extraction: A multicenter prospective observational study in Japan

Lower third molar extraction is the most common surgical treatment among routine dental and oral surgical procedures. while the surgical procedures for lower third molar extraction are well established, the difficulty of tooth extraction and the frequency of postoperative complications differ depending on the patient's background. To establish a management protocol for the lower third molars, the prevalence of and risk factors for postoperative complications after lower third molar extraction were investigated in a large number of Japanese patients in a multicenter prospective study. During 6 consecutive months in 2020, 1826 lower third molar extractions were performed at the 20 participating institutions. The medical records of the patients were reviewed, and relevant data were extracted. The prevalence of and risk factors for postoperative complications were analyzed. The prevalence of postoperative complications after lower third molar extraction was 10.0%. Multivariate analysis indicated that age (≤32 vs >32, odds ratio [OR]: 1.428, 95% confidence interval [95% CI]: 1.040-1.962, P < .05), the radiographic anatomical relationship between the tooth roots and mandibular canal (overlapping of the roots and canal vs no close anatomical relationship between the roots and the superior border of the canal, OR: 2.078, 95% CI: 1.333-3.238, P < .01; overlapping of the roots and canal vs roots impinging on the superior border of the canal, OR: 1.599, 95% CI: 1.050-2.435, P < .05), and impaction depth according to the Pell and Gregory classification (position C vs position A, OR: 3.7622, 95% CI: 2.079-6.310, P < .001; position C vs position B, OR: 2.574, 95% CI: 1.574-4.210, P < .001) are significant independent risk factors for postoperative complications after lower third molar extraction. These results suggested that higher age and a deeply impacted tooth might be significant independent risk factors for postoperative complications after lower third molar extraction.

Evaluation of Infection and Effective Factors in Impacted Mandibular Third Molar Surgeries: A Cross-Sectional Study

Background and Aim. Some complications, including infection, may occur following the surgeries of impacted teeth. In order to reduce the risk of infection, it is necessary to evaluate the risk factors of infection after third molar surgeries. Although research has been published in this area, the risk factors and causes of infection are still unclear. This study aimed to investigate infection incidence and effective factors in hard tissue impacted mandibular third molar surgeries in the Iranian population. Materials and Methods. This cross-sectional study was performed on 148 patients. The incidence of infection was recorded one week, two weeks, and one month after surgery. Independent variables included age, gender, the presence of periapical radiolucent lesions measuring ≥3 mm, the caries of the adjacent second molar, education level of the surgeon, difficulty index, suture type, and flap type. The outcome variable was the incidence of infection. Results. Among the study subjects, 37.2% were male and 62.8% were female. The mean age was 25.24 ± 4.31 years at the time of surgery. Although early onset infection occurred in 3.4% of patients, none of them developed a delayed-onset infection during the four weeks after surgery. Pederson difficulty index (OR = 3.81, $P=0.03$ ) and the education level of the surgeon (OR = 0.14, $P=0.021$ ) were associated with postop infection. Conclusions. Based on the results of the current study, postop infection was rare. Furthermore, both the Pederson difficulty index and the education level of the surgeon could predict the risk of infection after impacted mandibular third molar surgeries.

[Prevention of inflammatory complications after surgical extraction of mandibular third molars]

BACKGROUND

Inflammatory complications are the most prevalent problems after surgical extraction of mandibular third molars. The main options for prevention are prophylactic antibiotics usage before surgery or in the postoperative period; a method of postoperative management of a tooth socket, implying healing by primary or secondary closure. Each of the postoperative management types has advantages and disadvantages.

OBJECTIVE

The aim of the study was to compare complete suturing versus iodoform gauze packing of tooth socket for prevention of inflammatory complications after mandibular third molar removal.

MATERIAL AND METHODS

A retrospective cohort study was performed. The medical records of 273 patients who underwent mandibular third molar extraction for orthodontic indications were analyzed. Data of 100 patients were included, in 50 cases the postoperative management was carried out using iodoform packing, in other 50 cases complete suturing was performed. Depending on the type of data and distribution, we used the chi-squared test, Fisher's exact test, Student's t-test, Mann-Whitney U test. A p<0.05 was needed to achieve statistical significance.

RESULTS

Alveolitis developed in 8 % cases of iodoform gauze packing and 34% cases of suturing. The differences are statistically significant (p=0.003). The total rehabilitation period (days) in patients with no alveolitis using iodoform gauze packing was 8 (7; 31) (Me (Q1; Q3)), using complete socket suturing was 7 (7; 8) (Me (Q1; Q3)), the differences are statistically significant (p=0.003).

CONCLUSION

The best option for the prophylaxis of alveolitis after surgical extraction of mandibular third molar is secondary closure using iodoform gauze packing. However, in the cases with no alveolitis when complete suturing was performed, healing occurred much faster, which justifies the development of an alternative method for third molar socket healing.

Delayed-onset infections after lower third molar surgery: a Hungarian case-control study

OBJECTIVE

Delayed-onset infection is defined as infectious swelling and trismus accompanied by pain or the presence of suppuration starting approximately 30 days after surgery. This study aimed to describe the occurrence and potential predisposing factors of delayed-onset infection.

STUDY DESIGN

A retrospective case-control study of 223 lower third molar surgeries was performed. Participants were selected from among 1102 outpatients who underwent surgery between January 2013 and June 2018 at Semmelweis University. The inclusion criterion for the case group was inflammation of the operated area after suture removal. Patients in the control group were healthy nonsmokers <26 years old who healed without complication. Statistical analysis was performed using the Shapiro-Wilk test, the Mann-Whitney U test, and Fisher's exact test.

RESULTS

Complications occurred only in patients <26 years old approximately 29.5 days after surgery. A significantly higher risk was observed for younger age, total soft tissue coverage, deeper impaction, lower Nolla stage (P < .001), mesioangular direction (P = .002), and full bone coverage (P < .05). Distal space was inversely correlated with complications (P < .001).

CONCLUSIONS

Lower Nolla stage, total soft tissue coverage, lack of distal space, deeper impaction, or mesioangular tilt may promote delayed-onset infection. Follow-up of at-risk patients and the maintenance of oral hygiene are recommended.

The Evaluation of Further Complications after the Extraction of the Third Molar Germ: A Pilot Study in Paediatric Dentistry

Some authors suggest germectomy to prevent the impaction of mandibular third molars, which can cause anterior crowding. The aim of the study, conducted with 2 years of follow-up, was to clarify when the extraction of the germ of the third molar is optimal, together with possible post-operative complications. A new surgical approach was performed through the application of a combined suture, which can provide better wound healing. The study was performed on 25 patients with a mean age of 15.44 ± 2.06. Based on orthodontic and surgical indications, 46 germectomies were performed. Follow-ups were conducted after 1 week, 2 weeks, 4 weeks, 1 year and 2 years. All procedures were carried out by the same operator and were standardized. Data analysis was conducted using R-Software. Statistical evaluation used the chi-squared test and the Monte Carlo test. The level of significance was set as 0.05. Results showed that out of 46 germectomies, the prevalence of complications was 4.2% for two patients (8%). Both complications were observed in male patients. In the first case, the patient (at Nolla stage 7) showed delayed onset infections after four weeks; in the second case, the patient (at Nolla stage 6) showed bleeding immediately after surgery and suture. With reference to delayed onset infections, no statistically significant association was found among gender (χ² = 0.719; p = 0.396), germ development stage (χ² = 2.595; p = 0.658) or Winter's classifications (χ² = 0.046; p = 0.829); similarly, no significant associations were found among bleeding, gender (χ² = 0.719; p = 0.396), germ development stage (χ² = 2.595; p = 0.658) or Winter's classification (χ² = 0.046; p = 0.829). From our results, it is also possible to state that post-operative complications following germectomy of the mandibular third molar germ in adolescence occur in a significantly reduced percentage of patients, so this oral surgery treatment becomes a reliable surgical technique in adolescence.

A New Type of Chronic Wound Infection after Wisdom Tooth Extraction: A Diagnostic Approach with 16S-rRNA Gene Analysis, Next-Generation Sequencing, and Bioinformatics

Delayed-onset infections are rare postoperative complications of lower third molar extractions. This article presents a case of a chronic combined hard and soft tissue infection after the extraction of a third molar, where the causative organisms could only be elucidated by molecular methods. Experimental 16S-rRNA gene analysis with next-generation sequencing and bioinformatics was used to identify the bacterial spectrum of the infection. 16S-rRNA gene analysis delivered the microbiome of the abscessing inflammation while standard culture and laboratory examinations were all sterile. The microbiome showed a mixed bacterial infection with a dominance of Delftia and Alcanivorax (spp.) besides other bacteria of the normal oral flora. Using 16S-rRNA-gene analysis, next-generation sequencing, and bioinformatics, a new type of chronic wound infection after wisdom tooth extraction was found. The property of Delftia and Alcanivorax (spp.) as water-affine environmental bacteria raises suspicion of infection from contaminated water from a dental unit. Thus, osteotomies of teeth should only be done with sterile cooling water. The 16S-rRNA gene analysis should become a part of the routine diagnostics in medical microbiology.

Comparison of efficacy of ozonated water, normal saline, and povidone-iodine after surgical removal of impacted mandibular third molars: A cross-sectional study

Background:

Surgical extraction of mandibular third molars is an important and one of the most frequently performed operative procedures in dentistry. There are a variety of postoperative complications that may follow this procedure. These include pain, trismus, infection, dry socket, or alveolar osteitis. Numerous techniques have been used for reducing these morbid conditions. These range from flap designs, suture placement, use of various irrigating solutions, etc.,

Aim:

The present study aimed to compare the effectiveness of three irrigating solutions: Ozonated water, normal saline, and povidone-iodine in reducing postoperative complications following surgical removal of impacted mandibular third molars.

Materials and Methods:

A total of 100 study participants formed the sample size of this study. Study subjects were categorized into three groups: Group I (third molar surgeries using ozonated water), Group II (third molar surgeries with normal saline irrigation), and Group III (third molar surgeries using povidone-iodine irrigation). Parameters studied postoperatively were alveolar osteitis (dry socket), pain, trismus, and infection after a week interval. All data obtained were entered in Microsoft Excel 2007 worksheets and Analysis of Variance (ANOVA) as a statistical tool was employed. A P value of < 0.01 was considered statistically significant.

Results:

It was found that ozonated water provided the best statistically proven results with comparison to normal saline and povidone-iodine in reducing the incidence of alveolar osteitis or dry socket and pain. No statistically significant difference was observed in the incidence of trismus and infection rate among three studied groups.

Conclusion:

Ozonated water is the best irrigating solution when compared to normal saline and povidone-iodine in terms of reduction in pain and dry socket after a 1-week duration.

What are the risk factors for postoperative infections of third molar extraction surgery: A retrospective clinical study?

BACKGROUND

This study aimed to identify (1) the predilection site of postoperative infection after third molar extraction surgery, (2) risk factors associated with postoperative infection, and (3) the cause of the difference between delayed- and early-onset infections.

MATERIALS AND METHODS

This retrospective study included 1010 patients (396 male, 614 female) who had ≥1 third molars extracted (2407; 812 maxilla, 1595 mandible). The risk factors were classified as attributes, general health, anatomic, and operative. Outcome variables were delayed- and early-onset infections.

RESULTS

Postoperative infection was completely absent in the maxilla, and all infections occurred in the mandible, with a probability of 1.94% (31/1595). Bivariate analysis for postoperative infection showed depth of inclusion and intraoperative hemostatic treatment to be significantly associated with the development of infections. Bivariate analysis for delayed- and early-onset infections showed simultaneous extraction of the left and right mandibular third molars to be prominent risk factors.

CONCLUSIONS

Postoperative infection occurs mainly in the mandible, and that in the maxilla is very rare. The risk of postoperative infection in the mandible was found to be related to the depth of inclusion and intraoperative hemostatic treatment. Simultaneous extraction of the left and right mandibular third molars appear to increase the risk of delayed-onset postoperative infection.

Third molar removal and its impact on quality of life: systematic review and meta-analysis

OBJECTIVE

The purpose of this systematic review was to assess the impact of third molar removal on patient's quality of life.

METHODS

To address the study purpose, investigators designed and implemented a systematic review. The primary outcome variable was the quality of life after third molar extraction. An electronic search was conducted through March, 2017, on the PUBMED, Virtual Health Library (VHL), Web of Science, and OVID, to identify relevant literatures. Research studies (randomized or non-randomized clinical trials) were included that evaluated the quality of life in individuals before and after third molar extraction, using validated measures of oral health-related quality of life with quantitative approach, besides procedures performed under local anesthesia. The R software was used to measure the mean difference on the quality of life between the preoperative period and follow-up days.

RESULTS

A total of 1141 studies were identified. Of this total, 13 articles were selected in the present systematic review, of which six studies were included in the meta-analysis. All of these 13 articles used the OHIP-14, and 4 of this 13 used OHQoLUK-16 to evaluate the quality of life. Regarding quality assessment, four of the 13 included studies in this review received a maximum score of 9 points, according to the Newcastle-Ottawa (NOS). The OHIP-14 mean score on the first postoperative day was 17.57 (95% CI 11.84-23.30, I² = 96%) higher than the preoperative period. On the seventh postoperative day, the quality of life assessed by OHIP-14 got worse again.

CONCLUSION

This systematic review revealed that the highest negative impact on quality of life of individuals submitted to third molar surgery was observed on the first postoperative day, decreasing over the follow-up period.