- Email: [email protected]
Female and Older Adult Patients (age ≥ 21 Years) had Slower Recovery After Third-Molar Surgery Compared with Males and Younger Adults in a US Study
DIAGNOSIS/TREATMENT/PROGNOSIS
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Recovery after third-molar surgery: the effects of age and sex. Phillips C, Gelesko S, Proffit WR, White RP Jr. Am J Orthod Dentofacial Orthop 2010;138(6):700.e1-8
REVIEWERS Poramate Pitak-Arnnop, DDS, PGDipClinSc (OMS), MSc, PhD, DSc Niels Christian Pausch, MD, DMD, PhD
PURPOSE/QUESTION To assess the effects of age and gender on quality-of-life recovery after third-molar surgery in patients treated in either community practices or academic centers
Female and Older Adult Patients (age $ 21 Years) had Slower Recovery After Third-Molar Surgery Compared with Males and Younger Adults in a US Study SUMMARY Subjects The sample included 958 healthy subjects (60% females; 85% white) treated in 21 clinical centers (9 academic centers and 12 community practices) with an unknown mean age (range 14-40 years). All subjects had 4 third molars to be removed. Exclusion criteria included being pregnant or lactating, having a history of psychiatric treatment, or radiographic evidence of severe periodontal disease.
Key Exposure/Study Factor
Cohort study
All subjects received third-molar surgery from fellows of the American Association of Oral and Maxillofacial Surgeons (AAOMS) or from residents with at least 1 year of post–dental school dentoalveolar surgical training. The study period was between 1997 and 2009. The standard surgery protocol in this study included common procedures in the United States: intravenous anesthesia, buccal access to third molars, and bone removal to access the third molars by using rotary instrumentation. The predictor variables were grouped as follows: demographic, anatomic, and operative. The demographic variables included age, gender, ethnicity, and education level. The anatomic variable was third-molar position in presurgery panoramic radiograph (1 or 2 third molars below the occlusal plane). The operative variables comprised bone removal, length of surgery, and degree of total difficulty. Bone removal (0 or 1 or 2 third molars) and length of surgery (# 20 minutes, > 20 to 30 minutes, > 30 to 40 minutes, and > 40 minutes) were ordinal data, whereas degree of difficulty was surgeon’s subjective estimate using a nominal scale of 1 (no difficulty) to 7 (maximal difficulty).
LEVEL OF EVIDENCE
Main Outcome Measure
Level 2: Limited-quality, patientoriented evidence
The main outcome variables were 3 quality-of-life (QoL) domains: daily lifestyle, oral function, and pain for 14 postoperative days. The first 2 domains were recorded using a 5-point Likert-type scale of 1 (no trouble) to 5 (a lot of trouble), whereas recovery from pain was defined as the number of days until pain medications were no longer needed. Subjects’ lifestyle comprised usual daily activities, social interactions, and recreation. Oral-function items included difficulty during mouth opening, chewing, and eating a regular diet.
SOURCE OF FUNDING The Oral and Maxillofacial Surgery Foundation, the American Association of Oral and Maxillofacial Surgeons, and the Dental Foundation of North America
TYPE OF STUDY/DESIGN
STRENGTH OF RECOMMENDATION GRADE Not applicable
J Evid Base Dent Pract 2011;11:196-199 1532-3382/$36.00 Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2011.09.014
Main Results Younger age (< 21 years) and male gender were individually associated with faster recovery for all QoL items (P < .01), except for ability to open the mouth in subjects at age 21 or older.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Conclusions The authors concluded that female and adult patients (age $ 21 years) should be informed before third-molar surgery about the likelihood of requiring more time for improvements in oral function, lifestyle, and pain recovery compared with male and younger patients (age < 21 years) following third-molar surgery.
COMMENTARY AND ANALYSIS Although Phillips et al highlighted some interesting information, there are 6 topic areas for discussion we would like to expand on. First, tooth extraction is one of the top 5 most fearevoking treatment procedures in dentistry.1 Many dental surgery patients, especially female patients, have high anxiety, and an anxious patient will experience heightened pain and fear during the surgical period. Risk factors for the development of postoperative anxiety and/ or posttraumatic stress disorder (PSTD) symptoms include preoperative exposure to trauma/dental trait anxiety, emotional distress/pain during treatment, long duration of the surgical procedure, and postoperative facial swelling.1-4 It has also been demonstrated that people with low income, socioeconomic status, and educational level tend to have high dental anxiety.2 In a British survey, 88% of 105 third-molar surgery patients felt that postoperative pain was the same as expectation, or less than expectation before surgery.5 This finding suggests that reassurance and appropriate anesthesia protocols or adequate pain management are important to third-molar surgery patients, and probably more important than overdetailed consent.1,2,5 Second, it is generally accepted that complications after third-molar removal are associated with a set of one or more of the following factors: age, gender, medical history, use of oral contraceptives, presence of pericoronitis, poor oral hygiene, smoking, type of impaction, relationship of third molar to the inferior alveolar nerve, surgical time, surgical technique, surgeon experience, use of perioperative antibiotics, use of topical antiseptics, use of intrasocket medications, and anesthetic technique.6 Common complications that are usually explained during the patient consent include nerve damage, dry socket, infection, hemorrhage, trismus, jaw fracture, pain, and iatrogenic damage to adjacent teeth.7 Many studies, however, have shown that a patient’s ability to remember risks or complications inherent in surgery is very poor, and, moreover, up to 50% of third-molar surgery patients are not informed about the risks of dental treatments. This can lead to patient discontent and litigation.8 In contrast, obtaining informed consent can increase a patient’s anxiety and stress.7 Meningaud et al9,10 suggest that level of anxiety and stress because of elective, non–life-threatening surgical procedures (eg, cosmetic surgery, face transplantation, wisdom tooth Volume 11, Number 4
removal) should be minimal or nil. Anxiety may cause behavioral and physiological changes, including subclinical heart ischemia. Stress probably impairs the patient’s comprehension of the detailed informed consent.7 The consent form of third-molar surgery usually includes information about possible risks and complications. As a result, it can increase the patient’s anxiety and stress. Casap et al7 found a rise in pulse rate and electrodermal activity after patients received overdetailed consent before third-molar surgery. This finding indicates an association between the extent of informed consent and the level of stress and anxiety.7 It is not known whether female and adult patients will have increased anxiety and stress after they receive detailed information, and whether they should be overinformed about third-molar surgery. To minimize a patient’s anxiety and stress, some authors recommend giving detailed consent during an earlier meeting (ie, at the preliminary checkup or consultation), and not immediately before the procedure.7 Coping-skill training and use of in vivo exposure to anxiety-exposure stimuli (the stimuli are in actual physical situations to allow the anxiety to attenuate and to address hypervigilance11) seem to be the most appropriate option for the management of anxiety in dental patients and the reduction of their anxiety level.4 Establishing a trusting relationship between the treating dentist/oral surgeon and the patient is also recommended.1 In fact, oral diseases or disorders have functional or psychosocial impacts, including delayed clinical healing, that influence QoL.12,13 Pain and inflammation (with difficulties on chewing and/or mouth opening) are the most influential factors affecting QoL after wisdomtooth surgery.14 A patient’s decision about the need for pain medications is linked to a level of dissatisfaction.13 Using nonsteroidal anti-inflammatory drugs (NSAIDs) not only reduces possible discomfort and emotional distress caused by physical postoperative complications (inflammation, swelling, pain, and other predictable sequelae), but also prevents the development of psychological complications after treatment. Using sedation or general anesthesia, however, does not reduce dental trait anxiety in the long term, and is less likely to lower anxiety during treatment than, for instance, a behavioral management approach.1 Third, it is important to emphasize that a patient’s auustonomy includes right to refuse treatment.15 Ferr Torres et al8 reported that 14 (16%) of 87 third-molar surgery patients were unaware that they could refuse the surgery. There is a possible link between a low education level and being unaware of treatment refusal.8 In some circumstances, third-molar surgery is decided primarily by the treating practitioner(s), with minimal or no patient participation, such as removal of asymptomatic third molars before orthodontic treatment, although it is probably a part of the treatment. This decision may be 197
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
considered paternalistic, regardless of the consent details. Once an orthodontic patient refuses the removal of wisdom teeth that do not interfere with the orthodontic treatment, the treatment plan should be modified rather than omitting the patient completely from the orthodontic treatment.15 Participation in treatment decision making contributes to high satisfaction of the third-molar surgery patients.8 Fourth, it should be noted that factors relevant to recovery after wisdom tooth removal remain controversial. Panduric et al16 reported that type of operative procedure and tooth position were associated with postoperative recovery, whereas the patient’s age, gender, habits, and perioperative antibiotic treatment were not. Patients’ postoperative QoL returned to the preoperative level at day 7 after the surgery. A recent study from the American Association of Oral and Maxillofacial Surgeons (AAOMS) showed that time to return to normal activities was fewer than 2 days (mean 6 SD, 1.4 6 1.8; range, 0-26) postsurgery. Most factors associated with duration of disability were immutable (eg, age, gender, and anatomic location or position of third molars). Practitioners may find information valuable in advising the patient about the expected duration of disability after third-molar removal.17 In general, with the exception of facial cosmetic interventions,18 female patients tend to have higher anxiety, stress, and dissatisfaction than male patients after several oral-maxillofacial surgical procedures, such as wisdom tooth removal,1,12 jaw reconstruction,19 and orthognatic surgery.20 Female gender, moreover, is associated with an increase in the duration of disabilities after thirdmolar surgery.17 The possible explanations are that the emotional impact of the surgical procedures is higher in female patients, and/or that women answer the research or survey questions more honestly than men.1 An obvious benefit of third-molar removal in young patients is that the recovery is usually faster than in adult patients. It may be becaause they have almost no history of negative (distressing or horrific) dental events; hence, anxiety, stress, and any long-lasting psychological scars are less developed.1 It must be borne in mind, however, that young patients (or their family or legally authorized representative) require the same/adequate consent information as do adult patients before the treatment. Having fewer complaints, more satisfaction, and faster recovery do not imply that incomplete consent and negligence are appropriate for pediatric patients.15 Particular attention should be paid to patients undergoing first-time third-molar surgery, because patients who experience several third-molar surgeries have better QoL than those undergoing the first-time surgery.14 In contrast, the greater the number of third molars removed, the longer the duration of disability.17 Another study from the AAOMS concluded that third-molar surgery in patients 25 years or older has minimal effect on the patients’ QoL.21 This finding does not support the 198
study results by Phillips et al, which showed that adult patients had slower recovery than younger patients. It is possible that there are factors affecting overall QoL of third-molar surgery patients other than clinical recovery. For example, patients with physical pain, functional limitations, psychological disability, and so forth, can still go to work because of limited sick or vacation days left or to keep a private enterprise running.14 Fifth, notable strengths of the Phillips et al study are its sample size, study design, and outcome measures. The large sample size increases the statistical power and strengthens the reliability of the analysis. Using a prospective study design minimizes selection and recall bias. Both predictor variables and outcome measures chosen to determine QoL are numerical, allowing for a more objective comparison17; however, all outcome variables in the Phillips et al study can vary based on the subject’s interpretation. Many factors can also influence their study results, such as perioperative therapy with systematic or topical antibiotics or corticosteroids, the surgeon’s skill, and the degree of difficulty. Recent meta-analyses showed that administration of corticosteroids produced a significant decrease of edema, pain, and trismus after third-molar surgery.22,23 In the Phillips et al study, intraoperative use of corticosteroids depended on the surgeon’s preference, making the study samples heterogeneous. This can apparently skew the study results. Last, the Phillips et al study findings are unlikely to change clinical decisions and practices (see editorial comments24). This is not surprising. Davis Sears et al25 found that more than 90% of 1850 outcome research studies in plastic surgery only confirmed the effectiveness of the existing treatments, without changing patient, surgeon, or treatment practices. For details on evidence-based oral and maxillofacial surgery, we refer the interested readers to our recent publications.26,27 If the Phillips et al study results are to be applicable to general populations, future research should be done to identify a method to reduce prolonged clinical recovery after third molar surgery in female and adult patients.
REFERENCES 1. de Jongh A, van Wijk AJ, Lindeboom JA. Psychological impact of third molar surgery: a 1-month prospective study. J Oral Maxillofac Surg 2011;69(1):59-65. 2. Yusa H, Onizawa K, Hori M, Takeda S, Takeda H, Fukushima S, et al. Anxiety measurements in university students undergoing third molar extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(1):23-7. 3. de Jongh A, Olff M, van Hoolwerff H, Aartman IH, Broekman B, Lindauer R, et al. Anxiety and post-traumatic stress symptoms following wisdom tooth removal. Behav Res Ther 2008;46(12):1305-10. 4. van Wijk AJ, de Jongh A, Lindeboom JA. Anxiety sensitivity as a predictor of anxiety and pain related to third molar removal. J Oral Maxillofac Surg 2010;68(11):2723-9. 5. Earl P. Patients’ anxieties with third molar surgery. Br J Oral Maxillofac Surg 1994;32(5):293-7.
December 2011
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE 6. Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am 2007;19(1):117-28. 7. Casap N, Alterman M, Sharon G, Samuni Y. The effect of informed consent on stress levels associated with extraction of impacted mandibular third molars. J Oral Maxillofac Surg 2008;66(5):878-81. 8. Ferr us-Torres E, Valmaseda-Castell on E, Berini-Aytes L, GayEscoda C. Informed consent in oral surgery: the value of written information. J Oral Maxillofac Surg 2011;69(1):54-8. 9. Meningaud JP, Servant JM, Herve C, Bertrand JC. Ethics and aims of cosmetic surgery: a contribution from an analysis of claims after minor damage. Med Law 2000;19(2):237-52. 10. Meningaud JP. La greffe de face. Rev Prat 2010;60(9):1247-9. 11. Virtual Reality and Phobias Web site. Available at: http://mmi. tudelft.nl/vret/index.php/Virtual_Reality_and_Phobias. Accessed August 27, 2011. 12. Ruvo AT, Shugars DA, White RP Jr, Phillips C. The impact of delayed clinical healing after third molar surgery on health-related quality-oflife outcomes. J Oral Maxillofac Surg 2005;63(7):929-35. 13. Shugars 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(12):1721-30. 14. van Wijk A, Kieffer JM, Lindeboom JH. Effect of third molar surgery on oral health-related quality of life in the first postoperative week using Dutch version of Oral Health Impact Profile-14. J Oral Maxillofac Surg 2009;67(5):1026-31. 15. Pitak-Arnnop P. Ethics in Maxillofacial and Facial Plastic Surgery [dissertation]. Paris: University Paris 5 (Rene Descartes); 2010. 16. Panduric DG, Brozovic J, Susic M, Katanec D, Bego K, Kobler P. Assessing health-related quality of life outcomes after the surgical removal of a mandibular third molar. Coll Antropol 2009;33(2):437-47. 17. Bienstock DA, Dodson TB, Perrott DH, Chuang SK. Prognostic factors affecting the duration of disability after third molar removal. J Oral Maxillofac Surg 2011;69(5):1272-7. 18. Dowling NA, Honigman RJ, Jackson AC. The male cosmetic surgery patient: a matched sample gender analysis of elective cosmetic surgery and cosmetic dentistry patients. Ann Plast Surg 2010;64(6): 726-31. 19. H€ olzle F, Kesting MR, H€ olzle G, Watola A, Loeffelbein DJ, Ervens J, et al. Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps. Int J Oral Maxillofac Surg 2007;36(9):802-6.
Volume 11, Number 4
20. Espeland L, Høgevold HE, Stenvik A. A 3-year patient-centred followup of 516 consecutively treated orthognathic surgery patients. Eur J Orthod 2008;30(1):24-30. 21. 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;63(8):1106-14. 22. Markiewicz MR, Brady MF, Ding EL, Dodson TB. Corticosteroids reduce postoperative morbidity after third molar surgery: a systematic review and meta-analysis. J Oral Maxillofac Surg 2008;66(9):1881-94. 23. Dan AE, Thygesen TH, Pinholt EM. Corticosteroid administration in oral and orthognathic surgery: a systematic review of the literature and meta-analysis. J Oral Maxillofac Surg 2010;68(9):2207-20. 24. Phillips C, Gelesko S, Proffit WR, White RP Jr. Recovery after thirdmolar surgery: the effects of age and sex. Am J Orthod Dentofacial Orthop 2010;138(6):700.e1-8. discussion 700-1. 25. Davis Sears E, Burns PB, Chung KC. The outcomes of outcome studies in plastic surgery: a systematic review of 17 years of plastic surgery research. Plast Reconstr Surg 2007;120(7):2059-65. 26. Pitak-Arnnop P, Hemprich A, Pausch NC. Evidence-based oral and maxillofacial surgery: some pitfalls and limitations. J Oral Maxillofac Surg 2011;69(1):252-7. 27. Pitak-Arnnop P, Sader R, Rapidis AD, Dhanuthai K, Bauer U, Herve C, et al. Publication bias in oral and maxillofacial surgery journals: an observation on published controlled trials. J Craniomaxillofac Surg 2010;38(1):4-10.
REVIEWERS Poramate Pitak-Arnnop, DDS, PGDipClinSc (OMS), MSc, PhD, DSc Niels Christian Pausch, MD, DMD, PhD Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, Scientific Unit for Clinical and Psychosocial Research, Evidence-Based Surgery and Ethics in Oral and Maxillofacial Surgery, Faculty of Medicine, University Hospital of Leipzig, Leipzig, Germany, Phone: þ49 341 97 21 100; Fax: þ49 341 97 21 109 [email protected] [email protected]
199
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Recovery after third-molar surgery: the effects of age and sex. Phillips C, Gelesko S, Proffit WR, White RP Jr. Am J Orthod Dentofacial Orthop 2010;138(6):700.e1-8
REVIEWERS Poramate Pitak-Arnnop, DDS, PGDipClinSc (OMS), MSc, PhD, DSc Niels Christian Pausch, MD, DMD, PhD
PURPOSE/QUESTION To assess the effects of age and gender on quality-of-life recovery after third-molar surgery in patients treated in either community practices or academic centers
Female and Older Adult Patients (age $ 21 Years) had Slower Recovery After Third-Molar Surgery Compared with Males and Younger Adults in a US Study SUMMARY Subjects The sample included 958 healthy subjects (60% females; 85% white) treated in 21 clinical centers (9 academic centers and 12 community practices) with an unknown mean age (range 14-40 years). All subjects had 4 third molars to be removed. Exclusion criteria included being pregnant or lactating, having a history of psychiatric treatment, or radiographic evidence of severe periodontal disease.
Key Exposure/Study Factor
Cohort study
All subjects received third-molar surgery from fellows of the American Association of Oral and Maxillofacial Surgeons (AAOMS) or from residents with at least 1 year of post–dental school dentoalveolar surgical training. The study period was between 1997 and 2009. The standard surgery protocol in this study included common procedures in the United States: intravenous anesthesia, buccal access to third molars, and bone removal to access the third molars by using rotary instrumentation. The predictor variables were grouped as follows: demographic, anatomic, and operative. The demographic variables included age, gender, ethnicity, and education level. The anatomic variable was third-molar position in presurgery panoramic radiograph (1 or 2 third molars below the occlusal plane). The operative variables comprised bone removal, length of surgery, and degree of total difficulty. Bone removal (0 or 1 or 2 third molars) and length of surgery (# 20 minutes, > 20 to 30 minutes, > 30 to 40 minutes, and > 40 minutes) were ordinal data, whereas degree of difficulty was surgeon’s subjective estimate using a nominal scale of 1 (no difficulty) to 7 (maximal difficulty).
LEVEL OF EVIDENCE
Main Outcome Measure
Level 2: Limited-quality, patientoriented evidence
The main outcome variables were 3 quality-of-life (QoL) domains: daily lifestyle, oral function, and pain for 14 postoperative days. The first 2 domains were recorded using a 5-point Likert-type scale of 1 (no trouble) to 5 (a lot of trouble), whereas recovery from pain was defined as the number of days until pain medications were no longer needed. Subjects’ lifestyle comprised usual daily activities, social interactions, and recreation. Oral-function items included difficulty during mouth opening, chewing, and eating a regular diet.
SOURCE OF FUNDING The Oral and Maxillofacial Surgery Foundation, the American Association of Oral and Maxillofacial Surgeons, and the Dental Foundation of North America
TYPE OF STUDY/DESIGN
STRENGTH OF RECOMMENDATION GRADE Not applicable
J Evid Base Dent Pract 2011;11:196-199 1532-3382/$36.00 Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2011.09.014
Main Results Younger age (< 21 years) and male gender were individually associated with faster recovery for all QoL items (P < .01), except for ability to open the mouth in subjects at age 21 or older.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Conclusions The authors concluded that female and adult patients (age $ 21 years) should be informed before third-molar surgery about the likelihood of requiring more time for improvements in oral function, lifestyle, and pain recovery compared with male and younger patients (age < 21 years) following third-molar surgery.
COMMENTARY AND ANALYSIS Although Phillips et al highlighted some interesting information, there are 6 topic areas for discussion we would like to expand on. First, tooth extraction is one of the top 5 most fearevoking treatment procedures in dentistry.1 Many dental surgery patients, especially female patients, have high anxiety, and an anxious patient will experience heightened pain and fear during the surgical period. Risk factors for the development of postoperative anxiety and/ or posttraumatic stress disorder (PSTD) symptoms include preoperative exposure to trauma/dental trait anxiety, emotional distress/pain during treatment, long duration of the surgical procedure, and postoperative facial swelling.1-4 It has also been demonstrated that people with low income, socioeconomic status, and educational level tend to have high dental anxiety.2 In a British survey, 88% of 105 third-molar surgery patients felt that postoperative pain was the same as expectation, or less than expectation before surgery.5 This finding suggests that reassurance and appropriate anesthesia protocols or adequate pain management are important to third-molar surgery patients, and probably more important than overdetailed consent.1,2,5 Second, it is generally accepted that complications after third-molar removal are associated with a set of one or more of the following factors: age, gender, medical history, use of oral contraceptives, presence of pericoronitis, poor oral hygiene, smoking, type of impaction, relationship of third molar to the inferior alveolar nerve, surgical time, surgical technique, surgeon experience, use of perioperative antibiotics, use of topical antiseptics, use of intrasocket medications, and anesthetic technique.6 Common complications that are usually explained during the patient consent include nerve damage, dry socket, infection, hemorrhage, trismus, jaw fracture, pain, and iatrogenic damage to adjacent teeth.7 Many studies, however, have shown that a patient’s ability to remember risks or complications inherent in surgery is very poor, and, moreover, up to 50% of third-molar surgery patients are not informed about the risks of dental treatments. This can lead to patient discontent and litigation.8 In contrast, obtaining informed consent can increase a patient’s anxiety and stress.7 Meningaud et al9,10 suggest that level of anxiety and stress because of elective, non–life-threatening surgical procedures (eg, cosmetic surgery, face transplantation, wisdom tooth Volume 11, Number 4
removal) should be minimal or nil. Anxiety may cause behavioral and physiological changes, including subclinical heart ischemia. Stress probably impairs the patient’s comprehension of the detailed informed consent.7 The consent form of third-molar surgery usually includes information about possible risks and complications. As a result, it can increase the patient’s anxiety and stress. Casap et al7 found a rise in pulse rate and electrodermal activity after patients received overdetailed consent before third-molar surgery. This finding indicates an association between the extent of informed consent and the level of stress and anxiety.7 It is not known whether female and adult patients will have increased anxiety and stress after they receive detailed information, and whether they should be overinformed about third-molar surgery. To minimize a patient’s anxiety and stress, some authors recommend giving detailed consent during an earlier meeting (ie, at the preliminary checkup or consultation), and not immediately before the procedure.7 Coping-skill training and use of in vivo exposure to anxiety-exposure stimuli (the stimuli are in actual physical situations to allow the anxiety to attenuate and to address hypervigilance11) seem to be the most appropriate option for the management of anxiety in dental patients and the reduction of their anxiety level.4 Establishing a trusting relationship between the treating dentist/oral surgeon and the patient is also recommended.1 In fact, oral diseases or disorders have functional or psychosocial impacts, including delayed clinical healing, that influence QoL.12,13 Pain and inflammation (with difficulties on chewing and/or mouth opening) are the most influential factors affecting QoL after wisdomtooth surgery.14 A patient’s decision about the need for pain medications is linked to a level of dissatisfaction.13 Using nonsteroidal anti-inflammatory drugs (NSAIDs) not only reduces possible discomfort and emotional distress caused by physical postoperative complications (inflammation, swelling, pain, and other predictable sequelae), but also prevents the development of psychological complications after treatment. Using sedation or general anesthesia, however, does not reduce dental trait anxiety in the long term, and is less likely to lower anxiety during treatment than, for instance, a behavioral management approach.1 Third, it is important to emphasize that a patient’s auustonomy includes right to refuse treatment.15 Ferr Torres et al8 reported that 14 (16%) of 87 third-molar surgery patients were unaware that they could refuse the surgery. There is a possible link between a low education level and being unaware of treatment refusal.8 In some circumstances, third-molar surgery is decided primarily by the treating practitioner(s), with minimal or no patient participation, such as removal of asymptomatic third molars before orthodontic treatment, although it is probably a part of the treatment. This decision may be 197
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
considered paternalistic, regardless of the consent details. Once an orthodontic patient refuses the removal of wisdom teeth that do not interfere with the orthodontic treatment, the treatment plan should be modified rather than omitting the patient completely from the orthodontic treatment.15 Participation in treatment decision making contributes to high satisfaction of the third-molar surgery patients.8 Fourth, it should be noted that factors relevant to recovery after wisdom tooth removal remain controversial. Panduric et al16 reported that type of operative procedure and tooth position were associated with postoperative recovery, whereas the patient’s age, gender, habits, and perioperative antibiotic treatment were not. Patients’ postoperative QoL returned to the preoperative level at day 7 after the surgery. A recent study from the American Association of Oral and Maxillofacial Surgeons (AAOMS) showed that time to return to normal activities was fewer than 2 days (mean 6 SD, 1.4 6 1.8; range, 0-26) postsurgery. Most factors associated with duration of disability were immutable (eg, age, gender, and anatomic location or position of third molars). Practitioners may find information valuable in advising the patient about the expected duration of disability after third-molar removal.17 In general, with the exception of facial cosmetic interventions,18 female patients tend to have higher anxiety, stress, and dissatisfaction than male patients after several oral-maxillofacial surgical procedures, such as wisdom tooth removal,1,12 jaw reconstruction,19 and orthognatic surgery.20 Female gender, moreover, is associated with an increase in the duration of disabilities after thirdmolar surgery.17 The possible explanations are that the emotional impact of the surgical procedures is higher in female patients, and/or that women answer the research or survey questions more honestly than men.1 An obvious benefit of third-molar removal in young patients is that the recovery is usually faster than in adult patients. It may be becaause they have almost no history of negative (distressing or horrific) dental events; hence, anxiety, stress, and any long-lasting psychological scars are less developed.1 It must be borne in mind, however, that young patients (or their family or legally authorized representative) require the same/adequate consent information as do adult patients before the treatment. Having fewer complaints, more satisfaction, and faster recovery do not imply that incomplete consent and negligence are appropriate for pediatric patients.15 Particular attention should be paid to patients undergoing first-time third-molar surgery, because patients who experience several third-molar surgeries have better QoL than those undergoing the first-time surgery.14 In contrast, the greater the number of third molars removed, the longer the duration of disability.17 Another study from the AAOMS concluded that third-molar surgery in patients 25 years or older has minimal effect on the patients’ QoL.21 This finding does not support the 198
study results by Phillips et al, which showed that adult patients had slower recovery than younger patients. It is possible that there are factors affecting overall QoL of third-molar surgery patients other than clinical recovery. For example, patients with physical pain, functional limitations, psychological disability, and so forth, can still go to work because of limited sick or vacation days left or to keep a private enterprise running.14 Fifth, notable strengths of the Phillips et al study are its sample size, study design, and outcome measures. The large sample size increases the statistical power and strengthens the reliability of the analysis. Using a prospective study design minimizes selection and recall bias. Both predictor variables and outcome measures chosen to determine QoL are numerical, allowing for a more objective comparison17; however, all outcome variables in the Phillips et al study can vary based on the subject’s interpretation. Many factors can also influence their study results, such as perioperative therapy with systematic or topical antibiotics or corticosteroids, the surgeon’s skill, and the degree of difficulty. Recent meta-analyses showed that administration of corticosteroids produced a significant decrease of edema, pain, and trismus after third-molar surgery.22,23 In the Phillips et al study, intraoperative use of corticosteroids depended on the surgeon’s preference, making the study samples heterogeneous. This can apparently skew the study results. Last, the Phillips et al study findings are unlikely to change clinical decisions and practices (see editorial comments24). This is not surprising. Davis Sears et al25 found that more than 90% of 1850 outcome research studies in plastic surgery only confirmed the effectiveness of the existing treatments, without changing patient, surgeon, or treatment practices. For details on evidence-based oral and maxillofacial surgery, we refer the interested readers to our recent publications.26,27 If the Phillips et al study results are to be applicable to general populations, future research should be done to identify a method to reduce prolonged clinical recovery after third molar surgery in female and adult patients.
REFERENCES 1. de Jongh A, van Wijk AJ, Lindeboom JA. Psychological impact of third molar surgery: a 1-month prospective study. J Oral Maxillofac Surg 2011;69(1):59-65. 2. Yusa H, Onizawa K, Hori M, Takeda S, Takeda H, Fukushima S, et al. Anxiety measurements in university students undergoing third molar extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(1):23-7. 3. de Jongh A, Olff M, van Hoolwerff H, Aartman IH, Broekman B, Lindauer R, et al. Anxiety and post-traumatic stress symptoms following wisdom tooth removal. Behav Res Ther 2008;46(12):1305-10. 4. van Wijk AJ, de Jongh A, Lindeboom JA. Anxiety sensitivity as a predictor of anxiety and pain related to third molar removal. J Oral Maxillofac Surg 2010;68(11):2723-9. 5. Earl P. Patients’ anxieties with third molar surgery. Br J Oral Maxillofac Surg 1994;32(5):293-7.
December 2011
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE 6. Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am 2007;19(1):117-28. 7. Casap N, Alterman M, Sharon G, Samuni Y. The effect of informed consent on stress levels associated with extraction of impacted mandibular third molars. J Oral Maxillofac Surg 2008;66(5):878-81. 8. Ferr us-Torres E, Valmaseda-Castell on E, Berini-Aytes L, GayEscoda C. Informed consent in oral surgery: the value of written information. J Oral Maxillofac Surg 2011;69(1):54-8. 9. Meningaud JP, Servant JM, Herve C, Bertrand JC. Ethics and aims of cosmetic surgery: a contribution from an analysis of claims after minor damage. Med Law 2000;19(2):237-52. 10. Meningaud JP. La greffe de face. Rev Prat 2010;60(9):1247-9. 11. Virtual Reality and Phobias Web site. Available at: http://mmi. tudelft.nl/vret/index.php/Virtual_Reality_and_Phobias. Accessed August 27, 2011. 12. Ruvo AT, Shugars DA, White RP Jr, Phillips C. The impact of delayed clinical healing after third molar surgery on health-related quality-oflife outcomes. J Oral Maxillofac Surg 2005;63(7):929-35. 13. Shugars 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(12):1721-30. 14. van Wijk A, Kieffer JM, Lindeboom JH. Effect of third molar surgery on oral health-related quality of life in the first postoperative week using Dutch version of Oral Health Impact Profile-14. J Oral Maxillofac Surg 2009;67(5):1026-31. 15. Pitak-Arnnop P. Ethics in Maxillofacial and Facial Plastic Surgery [dissertation]. Paris: University Paris 5 (Rene Descartes); 2010. 16. Panduric DG, Brozovic J, Susic M, Katanec D, Bego K, Kobler P. Assessing health-related quality of life outcomes after the surgical removal of a mandibular third molar. Coll Antropol 2009;33(2):437-47. 17. Bienstock DA, Dodson TB, Perrott DH, Chuang SK. Prognostic factors affecting the duration of disability after third molar removal. J Oral Maxillofac Surg 2011;69(5):1272-7. 18. Dowling NA, Honigman RJ, Jackson AC. The male cosmetic surgery patient: a matched sample gender analysis of elective cosmetic surgery and cosmetic dentistry patients. Ann Plast Surg 2010;64(6): 726-31. 19. H€ olzle F, Kesting MR, H€ olzle G, Watola A, Loeffelbein DJ, Ervens J, et al. Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps. Int J Oral Maxillofac Surg 2007;36(9):802-6.
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20. Espeland L, Høgevold HE, Stenvik A. A 3-year patient-centred followup of 516 consecutively treated orthognathic surgery patients. Eur J Orthod 2008;30(1):24-30. 21. 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;63(8):1106-14. 22. Markiewicz MR, Brady MF, Ding EL, Dodson TB. Corticosteroids reduce postoperative morbidity after third molar surgery: a systematic review and meta-analysis. J Oral Maxillofac Surg 2008;66(9):1881-94. 23. Dan AE, Thygesen TH, Pinholt EM. Corticosteroid administration in oral and orthognathic surgery: a systematic review of the literature and meta-analysis. J Oral Maxillofac Surg 2010;68(9):2207-20. 24. Phillips C, Gelesko S, Proffit WR, White RP Jr. Recovery after thirdmolar surgery: the effects of age and sex. Am J Orthod Dentofacial Orthop 2010;138(6):700.e1-8. discussion 700-1. 25. Davis Sears E, Burns PB, Chung KC. The outcomes of outcome studies in plastic surgery: a systematic review of 17 years of plastic surgery research. Plast Reconstr Surg 2007;120(7):2059-65. 26. Pitak-Arnnop P, Hemprich A, Pausch NC. Evidence-based oral and maxillofacial surgery: some pitfalls and limitations. J Oral Maxillofac Surg 2011;69(1):252-7. 27. Pitak-Arnnop P, Sader R, Rapidis AD, Dhanuthai K, Bauer U, Herve C, et al. Publication bias in oral and maxillofacial surgery journals: an observation on published controlled trials. J Craniomaxillofac Surg 2010;38(1):4-10.
REVIEWERS Poramate Pitak-Arnnop, DDS, PGDipClinSc (OMS), MSc, PhD, DSc Niels Christian Pausch, MD, DMD, PhD Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, Scientific Unit for Clinical and Psychosocial Research, Evidence-Based Surgery and Ethics in Oral and Maxillofacial Surgery, Faculty of Medicine, University Hospital of Leipzig, Leipzig, Germany, Phone: þ49 341 97 21 100; Fax: þ49 341 97 21 109 [email protected] [email protected]
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