Journal of Dentistry Defence Section

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 15  |  Issue : 1  |  Page : 15--20

Impact of occupation on oral health outcomes following third molar surgery


Ankur Thakral, Mriganka Barman Chowdhuri 
 Military Dental Centre, New Delhi, India

Correspondence Address:
Ankur Thakral
Military Dental Centre, Delhi Cantt, New Delhi
India

Abstract

Context: The removal of third molar is advised in patients whose occupation precludes ready access to oral health care; however, there is a lack of directly applicable clinical research. Aims: The aim of this study is to assess the outcomes of impacted third molar removal on oral health-related quality of life in these patients. Settings and Design: The prospective study included 178 armed forces personnel who underwent the extraction of symptomatic impacted third molars at Military Dental Center over a 1-year period. Subjects and Methods: Oral health impact profile (OHIP-14) was utilized to analyze the outcomes before surgery and on postsurgical days 1, 7, and 14. Prevalence, extent, and severity scores were calculated. Statistical Analysis Used: The comparison of severity outcomes was analyzed by means of Friedman's test and Wilcoxon signed-rank test. Results: The present study revealed “painful aching in your mouth”, “uncomfortable to eat foods”, “diet been unsatisfactory,” “difficult to relax,” and “difficulty doing usual jobs” were reported “fairly often” or “very often” presurgery by 84%, 25%, 37%, 44%, and 17%, respectively. The median number of all 14 OHIP items reported “fairly often” or “very often” presurgery was 2 (IQ 1, 5.5). Prevalence, extent, and severity scores were the highest on postsurgical day 1 and decreased by postsurgical day 7 and 14. Comparison of severity outcomes revealed a statistically significant increase on postsurgical day 1 followed by significant reduction thereafter. Conclusions: Extraction of symptomatic impacted third molars significantly improve oral health-related quality of life in patients whose occupation dictate that they have to work in conditions isolated from expert treatment.



How to cite this article:
Thakral A, Chowdhuri MB. Impact of occupation on oral health outcomes following third molar surgery.J Dent Def Sect. 2021;15:15-20


How to cite this URL:
Thakral A, Chowdhuri MB. Impact of occupation on oral health outcomes following third molar surgery. J Dent Def Sect. [serial online] 2021 [cited 2021 Apr 14 ];15:15-20
Available from: http://www.journaldds.org/text.asp?2021/15/1/15/310960


Full Text



 Introduction



The failure of eruption of third molars is a very common condition.[1],[2] Impacted third molars are known to be associated with the risk of different disorders and complications. The removal of partially erupted or impacted third molars is the most common surgical procedure in dentistry. The indications for the removal of third molars were the subject of National Institutes of Health Consensus Conference held in the United States in 1979[3] and Scottish Intercollegiate Guidelines Network, 2000.[4] There are strong indications for the removal in cases of infection such as recurrent pericoronitis, cellulitis, abscess formation, untreatable pulpal/periapical pathology, un-restorable carious lesion, external root resorption, dentigerous cyst, or any associated pathology with third molar. Third molars may occasionally be extracted for autogenous transplantation to first molar socket, orthodontic reasons, tooth in a fracture line, or when required for osteotomies.[3],[4],[5],[6],[7],[8]

Scottish Intercollegiate Guidelines Network has advised the removal of unerupted and impacted third molars in patients whose occupation or lifestyle precludes ready access to dental care, or when medical or surgical conditions are likely to arise leading to difficulty or risk with their removal. This recommendation was based on evidence obtained from the expert committee reports or opinions and/or clinical experiences of respected authorities.[4]

There are numerous studies reported in the literature analyzing the quality of life outcomes following the removal of the third molars. However, as per authors' knowledge, an objective evaluation involving patients whose occupation influence ready access to oral health care has not been done previously. The patients reported to authors' dental center were armed forces personnel, and the purpose of the present study was to analyze the outcomes of partially erupted or impacted third molar removal on the oral health-related quality of life in these patients as they have to work in situations isolated from the expert treatment.

 Subjects and Methods



Clinical data

The present study involved 178 armed forces personnel who underwent extraction of symptomatic partially erupted or impacted third molar at Military Dental Center over a period of 1 year. It was prospective and was carried out after obtaining approval from the Institutional Ethical Committee. Written informed consent was obtained from patients before their inclusion in the study. The inclusion criteria dictated that patients be healthy (American Society of Anesthesiologists Risk Classification I, II), free of extensive periodontal disease (American Academy of Periodontology I, II) and between 25 and 35 years of age.

Method of collection of data

The short-form oral health impact profile (OHIP-14) developed by Slade[9] was utilized to analyze oral health-related quality of life outcomes before surgery (T1) and on postsurgical days 1 (T2), 7 (T3), and 14 (T4). This global oral health quality of life instrument had 14 questionnaires and was typed in both languages (English and Hindi) for ease of patient's understanding.

Surgical removal

Pre-operative patient assessment, clinical, and radiographic condition of unerupted third molar and routine blood investigations was carried out. A standard surgical protocol was followed such as local nerve block anesthesia, access to the third molars from buccal aspect, bone removal with rotary instruments and/or tooth sectioning, socket curettage, and surgical closure [Figure 1]. Details of the surgical procedure were recorded, and patients were recalled on postoperative days 1, 7, and 14 for follow-up and to collect postsurgical recovery data.{Figure 1}

Statistical analysis

All data were processed and tabulated using the SPSS Statistical Analysis Package version 17.0 (SPSS Inc., Chicago, IL, USA). Prevalence, extent, and severity were calculated presurgery and on postsurgical days 1, 7, and 14. The prevalence was calculated as the percentage of people reporting 1 or more OHIP-14 items either “fairly often” or “very often”. Extent score was computed as the number of OHIP-14 items reported “fairly often” or “very often”. Severity was calculated as the sum of OHIP-14 scores coded as follows: never (0), hardly ever (1), occasionally (2), fairly often (3), and very often (4). Comparison of the severity outcomes before and after the surgery was analyzed using the Friedman's test. If statistically significant P values were obtained, then Wilcoxon signed-rank test with Bonferroni adjustment was applied for multiple comparisons at various time intervals.

 Results



A total of 178 patients underwent the extraction of partially erupted or impacted third molars and out of them, 156 patients who fulfilled the inclusion criteria and followed the treatment protocol were included. The total number of partially erupted or impacted third molar were 386; out of which 161 were in the maxilla (41.71%) and 225 were in the mandible (58.29%). It ranged from one in 22 patients, two in 69 patients, three in 34 patients, and four in 31 patients. The mean age of these patients at the time of initial consultation was 27 years 8 months.

The OHIP-14 prevalence scores are summarized in [Table 1]. The pain items, “painful aching in your mouth,” and “uncomfortable to eat foods” were reported “fairly often” or “very often” presurgery by 84% and 25%, respectively. The psychological discomfort items, “been self-conscious,” and “felt tense” were reported “fairly often” or “very often” presurgery by 28% and 36%, respectively. The physical disability items “diet been unsatisfactory” and “had to interrupt meals” were reported “fairly often” or “very often” presurgery by 37% and 14% patients, respectively. The psychological disability items “difficult to relax” and “embarrassed” were reported “fairly often” or “very often” presurgery by 44% and 5% patients, respectively. The social disability items “irritable with other people” and “difficulty doing usual jobs” were reported “fairly often” or “very often” presurgery by 22% and 17%, respectively. The functional limitation items “trouble pronouncing words” and “sense of taste worsened” and the handicap items “life… less satisfying” and “totally unable to function” were reported “fairly often” or “very often” presurgery by 3% or less patients. After surgery, the prevalence of all OHIP-14 items was increased on postsurgical day 1 (T2) and decreased on postsurgical day 7 (T3) and postsurgical day 14 (T4).{Table 1}

The OHIP-14 extent scores are summarized in [Table 2]. The median number of all 14 OHIP items, 2 OHIP pain items and 12 OHIP nonpain items reported either “fairly often” or “very often” presurgery was 2 (IQ 1, 5.5), 1 (IQ 1, 1.75), and 1 (IQ 0, 3.5), respectively. The extent score increased to 5 (IQ 3, 8), 2 (IQ 1, 2), and 3 (IQ 1, 6.75) on postsurgical day 1, respectively, for all 14 OHIP items, 2 OHIP pain items, and 12 OHIP nonpain items. The extent scores were nil on postsurgical days 7 and 14.{Table 2}

The median sum of severity score for “painful aching in your mouth” out of possible 4 was 3 (IQ 3, 3.75) presurgery, 3 (IQ 3, 4) on postsurgical day 1, 2 (IQ 1, 2) on postsurgical day 7, and 1 (IQ 0, 1) on postsurgical day 7. The median sum of severity scores for remaining 14 OHIP items following a similar pattern were the highest on postsurgical day 1, decreasing on postsurgical day 7 and returning to levels below presurgery on postsurgical day 14. The OHIP-14 severity scores are summarized in [Table 3]. Statistical analysis of severity scores revealed the significant outcomes for all 14 OHIP items.{Table 3}

Multiple comparisons of severity outcomes are summarized in [Table 4]. Comparison of severity outcome for “painful aching in your mouth” revealed a slight but statistically nonsignificant increase on postsurgical day 1 and significant reduction in pain on postsurgical days 7 and 14. A statistically significant increase was noted with “uncomfortable to eat foods,” “diet been unsatisfactory,” “had to interrupt meals,” “trouble pronouncing words,” “difficult to relax,” “irritable with other people,” and “difficulty doing usual jobs” on postsurgical day 1 followed by statistically significant reduction on postsurgical days 7 and 14.{Table 4}

 Discussion



The prevalence of unerupted third molars varies widely and is influenced by age, gender, and ethnicity. There are the number of reasons for the removal of third molars where there is pathology in and around the third molar. The removal of third molar is advised in patients whose occupation precludes ready access to dental care; however, there is a lack of directly applicable clinical studies.[2] The focus of this study was to prospectively evaluate the patients undergoing third molar surgery whose occupation precludes ready access to dental care. In particular, this study provided reliable preoperative and postoperative oral health related quality of life data in this specific population. The present study revealed that presurgery “painful aching” was reported “often” or “very often” in 84% of patients as compared to 10% by Shugars et al.[10] and 37% by McNutt et al.[11] A significantly large number of patients were “uncomfortable to eat any foods,” “had to interrupt meals,” and “diet been unsatisfactory” leading to discomfort and physical disabilities. The median OHIP-14 extent score for all 14 items presurgery in our participants was 2 (IQ, 1–3.5) and for pain items was 1 (IQ, 1–1.75). Shugars et al.[10] reported a median OHIP-14 extent score of 0 (IQ, 0–5) for all 14 items and a median extent score of 0 (IQ, 0–2) for pain items. Collectively, the data suggest that the prevalence, extent, and severity predictors of pain and pain-related parameters in the present study were comparatively higher presurgery. The challenging work profile of these patients and restricted movements prevented them from specialized dental treatment. Besides an increased pain and suffering, it also resulted in an effective loss of manpower and military serving time once they were referred to specialist dental center for the management of symptomatic impacted third molars.

The psychological discomfort, psychological disability, and social disability items affecting the quality of life were significantly higher in our participants presurgery. This, apart from the pain of symptomatic third molar can partly be attributed to their work profile. The pain and discomfort of third molar exerted a negative impact and further enhanced the difficulties, stress, and fatigue these patients were already facing due to their work profile. Thus it can be concluded that occupation influenced oral health-related quality of life in patients with symptomatic impacted third molar.

The oral health-related quality of life outcomes had improved significantly in our patients following surgical intervention of third molar. The recovery was rapid and majority of them resumed normal oral function in 7 days or less. These outcomes will not be surprising to clinicians who routinely manage these problems. However, these findings are reassuring to the affected patients as the very nature of their work prevented them from specialized dental treatment.

The authors consider that routine clinical and radiographic assessment of the oral cavity for the management of impacted third molars in these patients at specialized dental centers should be carried out mandatorily before inducting them in remote and inaccessible locations. The aim of examination is to assess the eruption status of the third molars, periodontal status, caries, presence of local infection, resorption of the third molar and the adjacent tooth, orientation and relationship of the tooth to the inferior alveolar canal, occlusal relationship, temporomandibular joint function, regional lymph nodes, and any associated pathology. About 25%–60% of patients, depending on their age or gender, had clinical evidence of periodontal inflammatory disease as evidenced by periodontal probing depths of at least 4 mm.[12],[13] About 28%–77% of patients will have caries.[14],[15] Regarding the eruption status of such molars, total mucosal and bony coverage constitutes an effective barrier against bacterial invasion while partial mucosal coverage has been shown to favor the appearance of infectious complications (pericoronitis).[16],[17] Regarding the position of such molars, mesioangular and horizontal positions are associated with caries, root resorption, and periodontal disorders of the distal surface of the second molar.[17],[18],[19] The management approach should be individualized, rather than generalized and is determined by the perceived risk of eventual clinical manifestations if the teeth are not removed. Therefore, a prior vigilant oral examination will certainly reduce the pain and suffering of symptomatic impacted third molars in this subset of patient and thereby enhancing dental fit ness standards.

 Conclusions



The present study utilized OHIP-14 for evaluating the impact of occupation on oral health-related quality of life outcomes in military personnel. The authors agreed that another prospective study with a set of questionnaires probing more comprehensively whether the prospect of working in the remote areas increased the anxiety of third molar symptoms is necessary. It will generate the data regarding the impact of occupation in this subset of patient and will provide valuable information regarding improvement of oral health-related quality of life. However, based on the current body of scientific evidence, the present article emphasized that extraction of symptomatic impacted third molars significantly improve the oral health-related quality of life as their occupation dictate that they have to work in the areas and situations isolated from expert treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Garcia RI, Chauncey HH. The eruption of third molars in adults: A 10-year longitudinal study. Oral Surg Oral Med Oral Pathol 1989;68:9-13.
2Hugoson A, Kugelberg CF. The prevalence of third molars in a Swedish population. An epidemiological study. Community Dent Health 1988;5:121-38.
3Guralnick G, Laskin D. NIH consensus development conference for the removal of third molars. J Oral Surg 1980;38:235-6.
4Scottish Intercollegiate Guidelines Network. Management of Unerupted and Impacted Third Molar Teeth. Edinburgh: Royal College of Physicians; 2000.
5Knutsson K, Brehmer B, Lysell L, Rohlin M. Pathoses associated with mandibular third molars subjected to removal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:10-7.
6Liedholm R, Knutsson K, Lysell L, Rohlin M. Mandibular third molars: Oral surgeons' assessment of the indications for removal. Br J Oral Maxillofac Surg 1999;37:440-3.
7Lytle JJ. Indications and contraindications for removal of the impacted tooth. Dent Clin North Am 1979;23:333-46.
8Shepherd JP, Brickley M. Surgical removal of third molars. BMJ 1994;309:620-1.
9Slade GD. Derivation and validation of a short form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284-90.
10Shugars DA, Gentile MA, Ahmad N, Stavropoulos MF, Slade GD, Phillips C, et al. Assessment of oral health-related quality of life before and after third molar surgery. J Oral Maxillofac Surg 2006;64:1721-30.
11McNutt M, Partrick M, Shugars DA, Phillips C, White RP Jr. Impact of symptomatic pericoronitis on health-related quality of life. J Oral Maxillofac Surg 2008;66:2482-7.
12Venta I, Murtommaa H, Turtola L, Meurman J, Ylipaavalniemi P. Assessing the eruption of lower third molars on the basis of radiographic features. Br J Oral Maxillofac Surg 1991;29:259-62.
13Leone SA, Edenfield MJ, Cohen ME. Correlation of acute pericoronitis and the position of the mandibular third molar. Oral Surg Oral Med Oral Pathol 1986;62:245-50.
14Lysell L, Rohlin M. A study of indications used for removal of the mandibular third molar. Int J Oral Maxillofac Surg 1988;17:161-4.
15Eliasson S, Heimdahl A, Nordenram A. Pathological changes related to long-term impaction of third molars. A radiographic study. Int J Oral Maxillofac Surg 1989;18:210-2.
16Stanley HR, Alattar M, Collett WK, Stringfellow HR Jr., Spiegel EH. Pathological sequelae of “neglected” impacted third molars. J Oral Pathol 1988;17:113-7.
17Kugelberg CF, Ahlström U, Ericson S, Hugoson A, Kvint S. Periodontal healing after impacted lower third molar surgery in adolescents and adults. A prospective study. Int J Oral Maxillofac Surg 1991;20:18-24.
18Moss KL, Beck JD, Mauriello SM, Offenbacher S, White RP Jr. Third molar periodontal pathology and caries in senior adults. J Oral Maxillofac Surg 2007;65:103-8.
19Blakey GH, Marciani RD, Haug RH, Phillips C, Offenbacher S, Pabla T, et al. Periodontal pathology associated with asymptomatic third molars. J Oral Maxillofac Surg 2002;601227-33.