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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 1  |  Page : 43-48

Can associated pathology influence pain perception and oral health-related quality of life after surgical removal of impacted mandibular third molars? A comparative study in a Saudi Arabia population


1 Department of Oral and Maxillofacial Surgery, Najran Specialty Regional Dental Center, Medical Villlage Complex, Najran, Kingdom of Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, College of Health Sciences, Usmanu Danfodiyo University Sokoto, Sokoto, Nigeria
3 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Submission21-Dec-2021
Date of Acceptance31-Jan-2022
Date of Web Publication05-Apr-2022

Correspondence Address:
Ramat Oyebunmi Braimah
Najran Specialty Regional Dental Center, Medical Villlage Complex, Najran
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodd.jodd_46_21

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  Abstract 


Background: Influence of over-erupted/buccally erupted maxillary third molar and distal surface caries (DSC) of mandibular second molar on oral health-related quality of life (OHRQoL) is not found in the literature.
Materials and Methods: This prospective study was to evaluate the influence of associated pathology on OHRQoL after impacted mandibular third molar (IMTM) surgery. Demographics, indication for seeking IMTM removal, and presence of DSC and over-erupted/buccally erupted maxillary third molar were recorded. The Numeric Pain Scale and Arabic version of UK-OHRQoL instruments were used to evaluate pain and QoL after IMTM surgery. Analysis of variance was used statistically.
Results: A total of 90 (41 [45.6%] males and 49 [54.4%] females) patients were recruited. The mean age was 31.3 ± 6.7 years. Patients with no associated pathology had lesser pain and better QoL scores. The domain scores became significant at: symptom level, body function level, and personal level on postoperative day (POD) 5; symptom level, body function level, personal level, and social level on POD 7; and at social level only on POD 14. Mean overall QoL was significant on POD 5 and 7.
Conclusion: An over-erupted/buccally erupted maxillary third molar and mandibular second molar with DSC negatively affected pain perception and overall OHRQoL after surgical removal of IMTMs.

Keywords: Associated pathology, pain, quality of life, surgical extraction


How to cite this article:
Braimah RO, Ali-Alsuliman D, Makrami RM, Alwalah AS, Al-Sagoor ST, Taiwo AO, Ibikunle AA. Can associated pathology influence pain perception and oral health-related quality of life after surgical removal of impacted mandibular third molars? A comparative study in a Saudi Arabia population. J Dent Def Sect. 2022;16:43-8

How to cite this URL:
Braimah RO, Ali-Alsuliman D, Makrami RM, Alwalah AS, Al-Sagoor ST, Taiwo AO, Ibikunle AA. Can associated pathology influence pain perception and oral health-related quality of life after surgical removal of impacted mandibular third molars? A comparative study in a Saudi Arabia population. J Dent Def Sect. [serial online] 2022 [cited 2022 Nov 29];16:43-8. Available from: http://www.journaldds.org/text.asp?2022/16/1/43/342647




  Introduction Top


Studies have discussed extensively oral health-related quality of life (OHRQoL) following surgical extraction of impacted mandibular third molars (IMTMs).[1],[2],[3],[4],[5] However, literature search did not reveal any study on the influence of over-erupted/buccally erupted upper third molar and distal surface caries (DSC) of lower second molar tooth on pain perception and QoL following surgical extraction of IMTMs. Concomitant pathologies with IMTMs may be clinically obvious or concealed.[6] Vague complaints such as headache, pressure, or pain not related to the IMTM are reported by patients when concomitant pathologies are concealed. These vague complaints can confuse the surgeon leading to misdiagnosis.[6] It is therefore imperative to constantly monitor IMTM teeth for signs of any related pathology.[7] Such pathologies include caries and its sequelae on the distal aspect of lower second molar, periodontitis, pericoronitis, cysts, and benign tumors.[6] The IMTMs may be extracted because of these pathologies.[1]

Among the pathologies associated with IMTMs, DSC and its sequelae on the second molar tooth and buccally\over-erupted corresponding upper third molar are worthy of note regarding its influence on pain perception and OHRQoL after surgical removal of IMTMs. Studies have reported distal caries of the second molar tooth as the commonest pathology associated with IMTMs especially with mesio-angular and horizontal impactions because of the angulation.[6],[8],[9] When there is impaction of the lower wisdom tooth, the upper corresponding third molar tends to over-erupt into the space, thereby causing continuous trauma during function on the pericoronal flap. Extraction of this over-erupted third molar is indicated in such conditions.[10]

Literature search did not reveal any study evaluating the influence of distal surface root caries and its sequelae on the second molar tooth and buccally/over-erupted corresponding upper third molar on pain perception and OHRQoL following third molar surgery, hence the justification for the recent study.


  Materials and Methods Top


This comparative study was carried out in the Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, from January 2021 to April 2021. The Research and Ethics Committee of the General Directorate of Health Affairs in Najran gave approval for the study with protocol number KACST, KSA: H-11-N-081, IRB 2021'58 in compliance with the Helsinki Declaration. Healthy patients classified as ASA I were included while patients classified as ASA II-IV were excluded. After giving consent to partake in the study, patients' baseline (demographics) comprising age and gender, indication for seeking third molar removal, and associated pathology (distal lower second molar caries and its sequelae and buccally/over-erupted upper third molar) were recorded. Third molar impaction was classified based on Winter's[11] and Pell and Gregory[12] classifications.

Patients were randomly assigned into three groups:

  • Group A: Patients with IMTMs + DSC of the second mandibular molar teeth [Figure 1]
  • Group B: Patients with IMTMs + over-erupted/buccally erupted maxillary third molar [Figure 2]
  • Group C: Patients with IMTMs only [Figure 3].
Figure 1: Mesio-angular impaction of mandibular right third molar with distal caries of second molar communicating with the pulp

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Figure 2: Over-erupted opposing maxillary third molar that causes trauma on the lower pericoronal tissues during function

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Figure 3: Impacted mandibular third molars without opposing over-erupted maxillary third molar nor distal caries of second molar communicating with the pulp

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Intervention variables

Transalveolar extraction was performed by the same surgeon utilizing the standardized procedure under local anesthesia (2% lignocaine with 1:100,000 adrenaline). After surgery, the patients were given tablets augmentin 625 mg tid for 7 days, tabs ibuprofen 400 mg tid for 3 days, and chlorhexidine mouthwash qid for 1 week as take home medications. Follow-up appointments to monitor wound healing were given to all the participants.

Sample size determination

The sample size was determined through the use of a computer-based program utilizing the following formula for calculating sample size for comparative research studies:



where

N is the total of sample size for both comparison groups

D is the minimum expected difference between the two means (15 mm)

σ is the assumed standard deviation of each group (17.35) adopted from study by Alalwani et al.[13]

Zcrit is the standard normal deviate corresponding to selected significance criteria of 0.05 or confidence interval of 95%; it is a constant factor and equals 1.960.

Zpwr is the standard normal deviate corresponding to selected statistical power. It is a constant factor and equals 1.282.

N = 56.2 which was approximated to 57 patients for the 2 groups (28.5/group). Since there are 3 groups, we have 28.5 × 3 which gives 85.5 patients. This was approximated to a total of 86 patients. With 5% (4.0) attrition, this gives (86 + 4) = 90. Each group was allocated 30 patients each.

Definition of outcome variables

Evaluation of pain perception

Numeric Pain Rating Scale (0 = least pain while 10 = worst pain) was used in assessing preoperative and postoperative pains. The Numeric Pain Scale was developed into Google Forms, and patients were asked to complete the form in the clinic as preoperative pain value. Thereafter, the Google Forms was sent to each patient's mobile number on postoperative days (PODs) 1, 3, 5, 7, and 14. The Numeric Pain Scale was graded as follows: no pain = score 0, mild pain = score 1–3, moderate pain = score 4–6, and severe pain = score 7–10.

Evaluation of oral health-related quality of life

QoL was assessed pre- and postoperatively using the validated Arabic version of the 16 item United Kingdom OHRQoL Measure (UK-OHRQoL-16).[14] The UK-OHRQoL questionnaire was developed into Google Forms, and patients were asked to complete the form in the clinic as preoperative QoL. Subsequently, the Google Forms was sent to each patient's mobile number on PODs 1, 3, 5, 7, and 14 to complete. For UK-OHRQoL-16, there are four domains: (1) symptom level, (2) body function level, (3) at person level, and (4) at social level.

Data were stored and analyzed using IBM SPSS software version 25 for IOS (Armonk, NY, USA: IBM Corp.). Descriptive statistics was generated as part of the data analysis. Pearson Chi-square was used to compare the relationship among the different variables (gender, age group, indications for extraction, and tooth angulation). The psychometric properties of the UK-OHQoL-16 instrument were evaluated by means of Cronbach's α. The comparison of mean summative scores of the UK-OHQoL-16 questionnaire pre- and postoperatively was finalized using repeated measure multivariate analysis of variance. The level of statistical significance was set at P ≤ 0.05.


  Results Top


A total of 90 (41 (45.6%) males and 49 (54.4%) females) patients were recruited into the study. The M: F ratio was 1:1.2. The mean age of the study participants was 31.3 ± 6.7 years with age group 30–34 years constituting the majority. Other patient characteristics are shown in [Table 1]. The distribution of mean numeric pain score at pre- and PODs according to associated pathology is shown in [Table 2]. It was observed that patients with no associated pathology continuously presented with lesser pain score than those with distal second mandibular molar caries and its sequelae and buccally/over-erupted maxillary third molar. This became statistically significant on the pre- and PODs 3, 5, 7, and 14.
Table 1: Characteristics of subject participants distributed according gender

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Table 2: Distribution of mean numeric pain score at pre- and post-operative days according to associated pathology

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The psychometric properties of the UK-OHQoL-16 instrument evaluated by means of Cronbach's α showed values >0.7 on the pre- and PODs 1, 3, 5, 7, and 14 (0.921, 0.800, 0.786, 0.757, 0.755, and 0.786, respectively). Generally, mean domain scores of the UK-OHRQoL-16 continuously improved throughout the PODs, however, better score was observed in the “none pathology” subjects. This became statistically significant at symptom level (P = 0.001), body function level (P = 0.003), and personal level (P = 0.002) on POD 5; symptom level (P = 0.001), body function level (P = 0.001), personal level (P = 0.017), and social level (P = 0.049) on POD 7; and at social level (0.023) only on POD 14 [Table 3]. Similarly, mean distribution of overall QoL of the UKOHRQoL-16 scores continued to improve throughout the review periods with better mean value in the “none pathology” subjects. This became significant on PODs 5 and 7 (P = 0.006) when subjected to statistical analysis [Table 3].
Table 3: Mean distribution of domain scores and overall quality of life of the United Kingdom Oral Health-Related Quality of Life-16 according to associated pathology

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  Discussion Top


In the field of clinical dentistry and dental research, OHRQoL has significant implications.[15] The concept of OHRQoL is multidimensional and encompasses a subjective evaluation of individual's oral health, functional well-being, expectations, and satisfaction with care.[15] Literature is engorged with studies on prevalence of IMTMs and problems related to its extraction[16],[17],[18],[19] including OHRQoL following such procedures.[1],[3],[4],[20],[21],[22] However, to the best of our knowledge, literature search has not reported any study on the influence of over-erupted/buccally erupted maxillary third molar and DSC of mandibular second molar on pain perception and OHRQoL after surgical extraction of IMTMs.

Because of vague complaints from patients when concomitant pathologies with IMTM teeth are concealed,[10] such might negatively influence pain perception and OHRQoL following mandibular third molar extraction. Pain from the carious lesion may continue to be perceived by the patient as pain from the surgical site because of its close proximity.

IMTM angulation, especially mesio-angular [Figure 1] and horizontal [Figure 4] impactions, predisposes distal surface of second molar tooth to caries which often times originates at the cementoenamel junction.[8] Other closely related pathologies which may be associated with vague pain and OHRQoL include cervical burnout or root resorption.[10] In our study, patients with IMTMs + distal surface root caries of the second mandibular molar had poor pain experience and by extension poor OHRQoL following the surgery. In other to prevent this situation, the authors recommend restorative consultation to decide about restorability of the caries and/or its sequelae before the surgery. If the second molar tooth cannot be restored, then it is preferable to have it extracted along the IMTM to improve the patients' OHRQoL following the surgery. Campbell[10] has recommended that in advanced carious lesions when restoration is impossible, both the second and third molar teeth must be extracted.
Figure 4: Horizontal impaction of mandibular left third molar with distal caries of second molar communicating with the pulp

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Similarly, buccally\over-erupted corresponding maxillary third molar will continue to traumatize the buccal flap during function,[10] hence increasing pain around the flap and the surgical site. When there is impaction of the lower wisdom tooth, the upper corresponding maxillary third molar over-erupts into the space to assume functional position. This new position will continuously cause trauma during function on the pericoronal flap.[23] In the current study, patients with IMTM + over-erupted/buccally erupted maxillary third molars continuously have bad pain experience and poor OHRQoL throughout the review period as compared with those without. This is due to the continuous trauma on the surgical site with healing disruption. The authors recommend extraction of this over-erupted third molar in other to improve OHRQoL of these patients. Literature has also supported extractions in such conditions.[10]


  Conclusion Top


This study revealed that an over-erupted/buccally erupted corresponding maxillary third molar and unrestorable lower mandibular second molar with DSC and its sequelae will negatively affect pain perception and overall OHRQoL after surgical removal of IMTMs. We recommend simultaneous extraction of such teeth with the third molar surgery. More study is required in this aspect of OHRQoL after surgical extraction of IMTMs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Winter GB. Principles of Exodontias as Applied to Impacted Mandibular Third Molar. 3rd ed. St Louis (MO): American Medical Book Co; 1926.  Back to cited text no. 11
    
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Fisher EL, Garaas R, Blakey GH, Offenbacher S, Shugars DA, Phillips C, et al. Changes over time in the prevalence of caries experience or periodontal pathology on third molars in young adults. J Oral Maxillofac Surg 2012;70:1016-22.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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