AAOMS outcomes study on third molars

Symposia from surgery and the muscles become tonic. Another source of inaccuracy during the surgical procedure comes from using reference points to vertically position the maxilla that provide false information. This lecture will provide examples of these inaccuracies and demonstrate what can be done to prevent and manage them.

References Ellis E: Accuracy of model surgery: Evaluation of an old technique and introduction of a new one. J Oral Maxillofac Surg 48:1161 Ellis E, Tharanon W, Gambrell K: A study on the accuracy of facebow transfer: Effect of surgical prediction and postsurgical result. J Oral Maxillofac Surg 50:562, 1992 Ellis E: Bimaxillary surgery using an interim splint to reposition the maxilla. J Oral Maxillofac Surg 57:53, 1999

SYMPOSIUM ON DENTOALVEOLAR SURGERY Presented on Saturday, October 2, 2004, 10:30 am—12:30 pm Moderator: Louis K. Rafetto, DMD, Wilmington, DE

Review of the Current Indications for the Treatment of Third Molars: Based on the Parameters of Care Louis K. Rafetto, DMD, Wilmington, DE Debate how to manage resources for patient care. While recognizing the importance and impact of health policy discussions, surgeons remain responsible for making evidence-based health care decisions in the best interest of their patients. One area of great concern for practicing clinicians is how to identify and apply appropriate indications for the management of third molar teeth, since the majority of adolescents and young adults have third molars and face the need to decide whether to have them removed or to retain them with monitoring. Intentionally or not, the line has been blurred on the difference between “coverage” provided by third party carriers and “indications”, further confusing the decision-making process. Reflecting the scope of this problem, the literature is replete with articles regarding matters related to the evaluation and management of third molar teeth. In an effort to develop some measure of consensus, the American Association of Oral and Maxillofacial Surgeons convened a workshop on the management of the patients with third molar teeth, with its report issued in the Journal of Oral and Maxillofacial Surgery in 1994. In addition, indications for therapy were included as a part of the AAOMS Parameters of Care. In an effort to utilize this and other information in presenting a coherent position to the insurance industry and others, the AAOMS Committee on Health Care Programs distilled this information into a document that outlines these indication with clinical examples of each. This presentation will review these consensus criteria and briefly comment on how they compare with other published criteria such as those contained in the British Parameters of Care and those found in textbooks on oral and maxillofacial surgery. 16

References American Association of Oral and Maxillofacial Surgeons: Report of a workshop on the management of patients with third molar teeth. J Oral Maxillofac Surg. 52:1102, 1994 American Association of Oral and Maxillofacial Surgeons: Parameters and pathways: Clinical practice guidelines for oral and maxillofacial surgery. Dentoalveolar Surg 3:15, 2001 Peterson LJ: Principles and management of impacted teeth, in Peterson et al: Contemporary Oral and Maxillofacial Surgery (ed 4). Pp 184-213

AAOMS Outcomes Study on Third Molars David H. Perrott, DDS, MD, Salinas, CA Third molar surgery is among the most frequently performed procedures undertaken by the oral and maxillofacial surgeon (OMS). The purpose of this investigation was to complement the American Association of Oral and Maxillofacial Surgeons’ (AAOMS) Third Molar Clinical Trial in assessing the frequency of complications of third molar surgery, both intra-operatively and postoperatively, for patients 25 years of age or greater. This prospective study evaluated patients, 25 years of age or older, who were to undergo third molar surgery by OMSs practicing in the United States. The predictor variables were categorized as demographic, chronic conditions, medical risk factors, preoperative clinical description of third molars, intraoperative and post-operative complications, as well as quality of life issues (days of work missed or normal activity curtailed). The sample was provided by 63 surgeons, and was composed of 4,648 patients with 16,664 third molars who were 25 years of age or older of which 10,139 third molars were removed. Alveolar osteitis was the most frequently encountered post-operative problem (0.17-10.23%). Postoperative inferior alveolar nerve anesthesia/paresthesia occurred with a frequency of 0.45-0.69%, while lingual nerve anesthesia/paresthesia was calculated as 0.11%. All other complications also occurred with a frequency of less than 1%. The findings of this study indicate that third molar surgery in patients 25 years of age or older is associated with minimal morbidity, low incidence of post-operative AAOMS • 2004

Symposia complications, and minimal impact on the patient’s quality of life. References Blakey GH, White RP Jr, Offenbacher S, et al: Clinical/biological outcomes of treatment for pericoronitis. J Oral Maxillofac Surg 54: 1150, 1996 Shugars DA, Benson K, White RP Jr, et al: Developing a measure of patient perceptions of short-term outcomes of third molar surgery. J Oral Maxillofac Surg 54:1402, 1996 Conrad SM, Blakey GH, Shugars DA, et al: Patients’ perception of recovery following third molar surgery. J Oral Maxillofac Surg 57:1288, 1999

Caries Progression With Retained Third Molars Raymond P. White, Jr, DDS, PhD, Chapel Hill, NC The presence of caries remains a major reason for removal of third molars in young patients with good overall oral health. However, little data are available on the extent of this clinical problem. Caries is an infectious disease affecting an individual patient, and decisions about appropriate treatment of carious teeth depend in large part on patients’ overall caries experience. Because data on caries are limited in young adults, clinicians have almost no information to help them determine caries risk in third molars before detection clinically. In a cross-sectional analysis of data from patients at baseline, Shugars et al reported that one third of the study population had occlusal caries in third molars. Almost all of the patients with third molar caries experience had caries experience in a first or second molar. The primary outcome measure for our study of caries progression was caries experience on the occlusal surface of a third molar, first exposed after eruption. In our analysis caries experience was indicated as present if either a sealant, restoration, or caries was observed clinically or radiographically on the occlusal surface of a third molar or on any surface of either the first or second molar. All patients enrolled in the clinical trial with at least one third molar at the occlusal plane at baseline were included. Data from baseline and data from the most recent follow-up visit were analyzed. Baseline data and follow-up data from 211 patients were available for analysis. More patients were female, 55%, and Caucasian, 79%. The median age of the patients at baseline was 26.6 years (interquartile range 22.7 to 32.6 years). More patients were 25 years or older, 59%. The median time after baseline for follow-up data collection was 2.9 years (interquartile range 1.6 to 4.0 years). Overall, third molar occlusal caries experience increased from 29%, 61/211, of patients at baseline to 33%, AAOMS • 2004

69/211, at the most recent follow-up. In addition eight patients with caries at baseline had third molars removed because of caries. In the older age cohort, ⱖ25 years, 43% had third molar caries at baseline and at follow-up. All of the change over time in third molar caries status was in patients younger than 25 years. Data from this longitudinal trial suggest that caries experience is not unique to third molars either at baseline or at follow-up. Only 4 patients, 2%, at baseline and 3 patients, 1%, at follow-up, had occlusal third molar caries experience with no evidence of caries experience in a first or second molar. Further study may evolve predictors for third molar caries which may be applied prior to caries detection clinically. References Shugars DA, Jacks TM, White RP Jr, et al: Occlusal caries in patients with asymptomatic third molars. J Oral Maxillofac Surg (accepted) Jacks TM, Shugars DA, White RP Jr, et al: Progression of occlusal caries experience in patients with asymptomatic third molars. J Oral Maxillofac Surg 61:26, 2003 (suppl 1) Hugoson A, Kugelberg CF: The prevalence of third molars in a Swedish population. An epidemiological study. Commun Dent Health 5:121, 1987

Periodontal Disease Progression With Retained Third Molars George H. Blakey III, DDS, Chapel Hill, NC Blakey et al reported that 25% of 325 young, asymptomatic patients enrolled in a longitudinal trial had at least one periodontal probing depth ⱖ5 mm (PD) on the distal of a second molar or on a third molar. Almost all of the patients had at least 2 mm of attachment loss accompanying the increased PD, confirming a diagnosis of periodontitis in the third molar region. These same patients were otherwise periodontally healthy. Young adult patients are usually not examined for periodontal disease and most clinical studies do not assess the third molar region of the mouth. The patients, enrolled in the IRB approved clinical trial at the University of Kentucky and the University of North Carolina with all four retained third molars, were examined yearly for periodontal changes. Full mouth periodontal probing, six sites per tooth, was conducted to determine periodontal status. All patients had a periodontal prophylaxis at each follow-up visit after data collection. Panoramic radiographs were analyzed for third molar angulation and degree of eruption. Clinical periodontal data were available for analysis from baseline and 3 years of follow-up for 195 patients. At baseline 59% of this cohort of patients had at least one PD ⱖ4 mm on the distal of a second molar or around a third molar; 21% had a PD ⱖ5 mm. Over time one fifth 17