Risk Factors In Complication Of Wound Healing After Third Molar Surgery

Keywords

Extraction; Residents; Third Molar; Wound Healing.

Introduction

Third molar extraction is one of the most common procedures performed in dentistry. Although the overall complication rate is low and most complications are minor [1-4], efforts to limit intraoperative or postoperative complication may have a great impact in terms of enhancing patient outcome. Numerous studies have been devoted to evaluating all aspects of third molar surgery, including indications for removal [5-8], radiographic analysis for surgical planning [9-12], risk factors as well as complication by rate and type [13-16]. Overall complication rates range from 2.6% to 30.9% [17-20]. Factors reported to be associated with complication include age, gender, medications such as antibiotics, corticosteroids or oral contraceptive, smokings, previous infections, periodontitis etc [2, 21, 22]. The four most common postoperative complications of third molar extraction reported in literature are localised alveolar osteitis, infection, bleeding and paraesthesia. In the evaluation of quality of clinical care, the incidence of complication is merely one factor that is taken into consideration. Patient satisfaction is a key to patient compliance and business success of a dental clinic. A literature review summarised factors affecting patient satisfaction, interpersonal factors, convenience and the cost of facilities [23-25]. The aim of the study was to evaluate the risk factors and prevalence rate of complication of third molar extractions done by undergraduates in Saveetha Dental College and Hospitals.

Materials and Methods

This was a retrospective study which was performed in a university setting where the required data of patients who were diagnosed for third molar surgery in the department of oral and maxillofacial surgery at a private teaching hospital, Chennai from June 2019 to March 2020, was collected by reviewing patients records and the analysis of data of 86000 patients. The collected data was cross verified using photographs, reviewed by a reviewing expert and tabulated in Microsoft excel . The Sample size of the total number of patients treated for third molar surgery was n=529. The ethical approval for this study is obtained from the ethical committee(ethical approval number SDC/SIHEC/2020/ DIASDATA/0619-0320). The tabulated data was imported to SPSS software ( statistical package for social studies ) version 22.0 ( IBM corporation ) for statistical analysis . To minimize sampling bias, collection of data was done by simple random sampling methods within the university. There is high internal validity and low external validity. Incomplete , censored and repeated data were excluded from the study. The data was analyzed using a chisquare test and the level of statistical significance was set at 5%.

Results and Discussion

The following are the results obtained from the analysis. Total sample size is 529 extraction out of which 95.09% had satisfactory healing post extraction and 4.9% complication rate was seen. There was a higher rate of complication males (3.2%) when compared to females (1.7%). Among 21-30 years patients showed better satisfaction than the rest and the age group 31-40 & 41- 50 showed higher complication rate (1.32%) than the rest. Least complication rate was seen among upper right molars . Although the association did not show any significance. Figure 1 represents the association between gender and outcome of third molar extraction, Figure 2 represents the association age and outcome of third molar extraction and Figure 3 represents the association between the Extraction site and outcome of third molar extraction; these associations were statistically not significant (P>0.05

---

×

Figure 1:

Close

Figure 2. Bar graph showing the association between Age group and Outcome post third molar extraction. The X axis represents age distribution and Y axis represents the Number of Patients. Chi-square test was done and was found to be statistically not significant[chi square value - 2.637; p value(>0.05)]. From this graph the Age group 21-30 shows more satisfactory rates(Green) than the rest of the population who underwent extraction of third molars and patients in the age group 31-40 & 41-50 had the highest complication(Blue) rate of 1.32% each.

---

---

×

Figure 2:

Close

Figure 3. Bar Graph showing the association between Extraction site & Outcome of third molar extraction. The X axis represents Extraction Site and Y axis represents the Number of Patients. Chi-square test was done and was found to be statistically not significant[chi square value - 2.628; p value(>0.05)]. This graph shows that the satisfactory rate(Green) was mostly seen among the Lower Left Third Molars than the rest of the teeth with a rate 27.96% and there was equal distribution of complication rate(Blue) of 1.51% among the rest of the sites except for Upper Right Third Molar where the complication rate(Blue) was lesser comparatively.

---

---

×

Figure 3:

Close

Figure 3. Bar Graph showing the association between Extraction site & Outcome of third molar extraction. The X axis represents Extraction Site and Y axis represents the Number of Patients. Chi-square test was done and was found to be statistically not significant[chi square value - 2.628; p value(>0.05)]. This graph shows that the satisfactory rate(Green) was mostly seen among the Lower Left Third Molars than the rest of the teeth with a rate 27.96% and there was equal distribution of complication rate(Blue) of 1.51% among the rest of the sites except for Upper Right Third Molar where the complication rate(Blue) was lesser comparatively.

---

The specific aim of this study was to evaluate the complication related to third molar extraction and risk factors. The overall complication rate in this study was 4.9%. The majority of complications were related to inflammation of the extracted site and dry socket being the most common complication. The complication rates documented in this study were within the ranges reported in other studies. Chipasco et al., [26] found that 4.3% complication rate in the mandible and 1.2% in the maxilla among healthy patients while Muhonen et al., [18] reported an overall complication rate of 9%.

The study did not find significant associations between gender, age and Extraction site. Gender was often cited as a risk factor for complication. Many studies reported increased complications among females associated with oral contraceptives usage [27, 28]. However consistent with our findings, Heasman and Jacobs [29] and Larsen [27] did not find age to be associated with complications. Age is considered as a risk factor for post extraction complications in various studies. However, our findings did not corroborate with other studies. Though the results were not statistically significant , the age groups 31-40 and 41-50 years showed more complications than the other groups. A study related to American Association of Oral and Maxillofacial Surgeons age related third molar study [30-33] showed that patients over the age of 25 years were 46% likely to develop the complication that those under that age. Consistent with other studies, our results indicated that mandibular third molars were associated with an increased frequency of complications relative to maxillary third molars.

The study was geographically limited and predominantly consisted of the South Indian population. Data which were unclear were excluded thereby reducing the sample size. Within the limit of the study, it was found that most of the patients had satisfactory healing post third molar extraction. To ascertain the results of this study and to increase the level of significance, the sample size and the geographic area of coverage should be extended to at least most parts of South India. Conducting a multicentered study with extended geographic area and wide range of population in future we can obtain better results. Thus this knowledge of wound healing post third molar extraction and association with various parameters is essential in a dental practice for clinical implementation.

Conclusion

From this study we can conclude that there were fewer complications reported after third molar surgery done by undergraduate students. This is the first study to assess the complication rates of third molar surgery done by undergraduates.

Acknowledgement

The authors would like to acknowledge the help and support rendered by the Department of Public Health and Dentistry and the Department of Information Technology of Saveetha Dental College and Hospitals , SIMATS for their constant assistance for this research.

References

1. Lopes V, Mumenya R, Feinmann C, Harris M. Third molar surgery: an audit of the indications for surgery, post-operative complaints and patient satisfaction.
Br J Oral Maxillofac Surg. 1995 Feb;33(1):33-5. PMID: 7718526.
2. Berge TI, Bøe OE. Predictor evaluation of postoperative morbidity after surgical removal of mandibular third molars. Acta Odontol Scand. 1994 Jun;52(3):162-9. PMID: 8091963.
3. Prabakar J, John J, Srisakthi D. Prevalence of dental caries and treatment needs among school going children of Chandigarh. Indian J Dent Res. 2016 Sep-Oct;27(5):547-552. PMID: 27966516.
4. Prabakar J, John J, Arumugham IM, Kumar RP, Sakthi DS. Comparative Evaluation of the Viscosity and Length of Resin Tags of Conventional and Hydrophilic Pit and Fissure Sealants on Permanent Molars: An In vitro Study. Contemp Clin Dent. 2018 Jul-Sep;9(3):388-394. PMID: 30166832.
5. Elter JR, Cuomo CJ, Offenbacher S, White RP Jr. Third molars associated with periodontal pathology in the Third National Health and Nutrition Examination Survey. J Oral Maxillofac Surg. 2004 Apr;62(4):440-5. PMID: 15085510.
6. Prabakar J, John J, Arumugham IM, Kumar RP, Srisakthi D. Comparative Evaluation of Retention, Cariostatic Effect and Discoloration of Conventional and Hydrophilic Sealants - A Single Blinded Randomized Split Mouth Clinical Trial. Contemp Clin Dent. 2018 Sep;9(Suppl 2):S233-S239. PMID: 30294150.
7. Kumar RP, Vijayalakshmi B. Assessment of fluoride concentration in ground water in Madurai district, Tamil Nadu, India. Research Journal of Pharmacy and Technology. 2017;10(1):309.
8. INDIRAN MA. Awareness and attitude towards mass disaster and its management among house surgeons in a dental college and hospital in Chennai, India. Disaster Management and Human Health Risk V: Reducing Risk, Improving Outcomes. 2017 Sep 7;173:121.
9. Blaeser BF, August MA, Donoff RB, Kaban LB, Dodson TB. Panoramic radiographic risk factors for inferior alveolar nerve injury after third molar extraction. J Oral Maxillofac Surg. 2003 Apr;61(4):417-21. PMID: 12684956.
10. Rood JP, Shehab BA. The radiological prediction of inferior alveolar nerve injury during third molar surgery. Br J Oral Maxillofac Surg. 1990 Feb;28(1):20-5. PMID: 2322523.
11. . Kumar RP, Preethi R. Assessment of water quality and pollution of Porur, Chembarambakkam and Puzhal Lake. Research Journal of Pharmacy and Technology. 2017 Jul 1;10(7):2157-9.
12. . Samuel SR, Acharya S, Rao JC. School Interventions-based Prevention of Early-Childhood Caries among 3-5-year-old children from very low socioeconomic status: Two-year randomized trial. J Public Health Dent. 2020 Jan;80(1):51-60. PMID: 31710096.
13. Almendros-Marqués N, Berini-Aytés L, Gay-Escoda C. Influence of lower third molar position on the incidence of preoperative complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Dec;102(6):725-32. PMID: 17138172.
14. Kunkel M, Morbach T, Kleis W, Wagner W. Third molar complications requiring hospitalization. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Sep;102(3):300-6. PMID: 16920537.
15. Kim JC, Choi SS, Wang SJ, Kim SG. Minor complications after mandibular third molar surgery: type, incidence, and possible prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Aug;102(2):e4-11. PMID: 16876044.
16. Mathew MG, Samuel SR, Soni AJ, Roopa KB. Evaluation of adhesion of Streptococcus mutans, plaque accumulation on zirconia and stainless steel crowns, and surrounding gingival inflammation in primary molars: randomized controlled trial. Clin Oral Investig. 2020 Sep;24(9):3275-3280. PMID: 31955271.
17. Calhoun NR. Dry socket and other postoperative complications. Dent Clin North Am. 1971 Apr;15(2):337-48. PMID: 5313408.
18. Muhonen A, Ventä I, Ylipaavalniemi P. Factors predisposing to postoperative complications related to wisdom tooth surgery among university students. J Am Coll Health. 1997 Jul;46(1):39-42. PMID: 9248241.
19. Osborn TP, Frederickson G Jr, Small IA, Torgerson TS. A prospective study of complications related to mandibular third molar surgery. J Oral Maxillofac Surg. 1985 Oct;43(10):767-9. PMID: 2995624.
20. Khatri SG, Madan KA, Srinivasan SR, Acharya S. Retention of moisturetolerant fluoride-releasing sealant and amorphous calcium phosphate-containing sealant in 6-9-year-old children: A randomized controlled trial. J Indian Soc Pedod Prev Dent. 2019 Jan-Mar;37(1):92-98. PMID: 30804314.
21. Edwards DJ, Horton J, Shepherd JP, Brickley MR. Impact of third molar removal on demands for postoperative care and job disruption: does anaesthetic choice make a difference? Ann R Coll Surg Engl. 1999 Mar;81(2):119-23. PMID: 10364971.
22. Pratha AA, Prabakar J. Comparing the effect of Carbonated and energy drinks on salivary pH-In Vivo Randomized Controlled Trial. Research Journal of Pharmacy and Technology. 2019 Oct 1;12(10):4699-702.
23. . Newsome PR, Wright GH. A review of patient satisfaction: 2. Dental patient satisfaction: an appraisal of recent literature. Br Dent J. 1999 Feb 27;186(4 Spec No):166-70. PMID: 10205952.
24. Jayashri P, Sharma SG, Sharma M, Guleria P. Influence of naturally occurring phytochemicals on oral health. Research Journal of Pharmacy and Technology. 2019 Aug 1;12(8):3979-83.
25. Leelavathi L. Nicotine Replacement Therapy for Smoking Cessation-An Overview. Indian Journal of Public Health Research & Development. 2019 Nov 1;10(11).
26. Chiapasco M, De Cicco L, Marrone G. Side effects and complications associated with third molar surgery. Oral Surg Oral Med Oral Pathol. 1993 Oct;76(4):412-20. PMID: 8233418.
27. Larsen PE. Alveolar osteitis after surgical removal of impacted mandibular third molars. Identification of the patient at risk. Oral Surg Oral Med Oral Pathol. 1992 Apr;73(4):393-7. PMID: 1574298.
28. Catellani JE, Harvey S, Erickson SH, Cherkin D. Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis). J Am Dent Assoc. 1980 Nov;101(5):777-80. PMID: 6935267.
29. . Heasman PA, Jacobs DJ. A clinical investigation into the incidence of dry socket. Br J Oral Maxillofac Surg. 1984 Apr;22(2):115-22. PMID: 6585221.
30. Haug RH, Perrott DH, Gonzalez ML, Talwar RM. The American Association of Oral and Maxillofacial Surgeons Age-Related Third Molar Study. J Oral Maxillofac Surg. 2005 Aug;63(8):1106-14. doi: 10.1016/j. joms.2005.04.022. PMID: 16094577.
31. Neralla M, Jayabalan J, George R, Rajan J, P SKM HA. Role of nutrition in rehabilitation of patients following surgery for oral squamous cell carcinoma. International Journal of Research in Pharmaceutical Sciences. 2019 Oct 16;10(4):3197-203.
32. Prabakar J, John J, Arumugham IM, Kumar RP, Sakthi DS. Comparing the Effectiveness of Probiotic, Green Tea, and Chlorhexidine- and Fluoride-containing Dentifrices on Oral Microbial Flora: A Double-blind, Randomized Clinical Trial. Contemp Clin Dent. 2018 Oct-Dec;9(4):560-569. PMID: 31772463.
33. Mohapatra S, Kumar RP, Arumugham IM, Sakthi D, Jayashri P. Assessment of Microhardness of Enamel Carious Like Lesions After Treatment with Nova Min, Bio Min and Remin Pro Containing Toothpastes: An in Vitro Study. Indian Journal of Public Health Research & Development. 2019 Oct 1;10(10).