- Email: [email protected]
Patients’ perceptions of recovery after routine extraction of healthy premolars
ORIGINAL ARTICLE
Patients’ perceptions of recovery after routine extraction of healthy premolars Gavriel Chaushu,a Adrian Becker,b Rafael Zeltser,c Naomi Vasker,d Sari Branski,d and Stella Chaushue Tel Aviv and Jerusalem, Israel Introduction: In this prospective study, we evaluated patients’ perceptions of recovery after orthodontic premolar extractions. Methods: Thirty patients (18 girls, 12 boys, mean age 14.6 ⫾ 3.8 years) were given a health-related quality of life questionnaire to be completed each postoperative day (POD) for 7 days. The questionnaire was designed to assess each patient’s perception of recovery: pain, oral function, general activity measures, and other variables. The impact of possible predictor variables, such as age, sex, length of surgical procedure, number of simultaneous extractions, and time during the day, was assessed. Results: Severe pain (16.7%, 3.3%) and consumption of analgesics (70%, 13.2%) declined dramatically from POD 1 to POD 2. Improvements in oral function and other symptoms were evident by POD 2. Absence from school resembled interference in daily activities (POD 2). Age was the most significant predictor variable, with results showing delayed recoveries for patients older than 15 years. The most striking differences were reported for enjoying food (P ⬍.05), taste (P ⬍.05), and food stagnation (P ⬍.05). The number of extractions performed at the same appointment had no affect on posttreatment recovery. Conclusions: This study was designed to provide baseline health-related quality of life information with which to compare other surgical procedures frequently needed in orthodontic treatment, such as removal of third molars and exposure of impacted teeth. Additionally, it provides information for patients and clinicians on postoperative recovery after premolar orthodontic extractions. (Am J Orthod Dentofacial Orthop 2007;131:170-5)
T
ooth extraction is a common treatment consideration in the orthodontic management of dental crowding, or as a tool to compensate for jaw growth discrepancy and to improve facial esthetics. Previous studies reported extremely wide ranges (6.5%-83.5%) in the frequency of extractions in orthodontic treatment.1,2 Premolars are most frequently extracted.2 A possible reason for these differences in attitude toward extractions with often similar diagnoses might be a negative attitude from the patient, the parents, or the practitioner toward removal of teeth in general and in young patients in particular.1 A recent study showed that patients, in general, expected more delayed recovery than actually experia
Senior lecturer and head, Oral and Maxillofacial Surgery Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. Clinical associate professor, Department of Orthodontics, Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel. c Clinical associate professor, Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. d Dental student, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. e Clinical senior lecturer, Department of Orthodontics, Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel. Reprint requests to: Dr G. Chaushu, Oral and Maxillofacial Surgery Unit, Tel Aviv Sourasky Medical Center, 6 Weitzman St, Tel Aviv, Israel, 64239; e-mail, [email protected]. Submitted, May 2005; revised and accepted, June 2005. 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2005.06.024 b
170
enced and suggested that exaggerated negative expectations of postoperative recovery, in a dental patient with a high level of anxiety, might result in a slower recovery.3 Subjects with increased levels of anxiety both expected and experienced more delayed recovery than those with low anxiety levels. These results suggest that patients must be told the postoperative outcome of a proposed procedure, particularly when it pertains to surgery. Patients need to know what they can expect during recovery. The most frequent questions refer to postoperative pain and when the patient can return to work or school. To confront such issues, studies regarding quality of life and health-related quality of life (HRQOL) have been increasingly used in the last decade in all medical disciplines.4-10 There is little room for variation in the operative technique of the surgeon during orthodontic premolar extractions. Although orthodontic premolar extractions might seem routine and everyday occurrences for dental practitioners, they are feared by youngsters, perhaps because of negative representation of the procedure in the media, in conversations with people in general and children in particular, and as a frequent subject in derisive satire. Nevertheless, most information available to both clinicians and patients concerning postoperative recovery was gathered from personal communications between clinicians or 1-time and often highly embellished anecdotal experiences of friends
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who had similar procedures. Surprisingly, we found no study in the English literature focusing on either the immediate postoperative period or patients’ perceptions of the various aspects of recovery after orthodontic premolar extractions. Our aim in this prospective study was to assess patients’ perceptions of immediate postoperative recovery after orthodontic premolar extractions in the light of the established experience of the HRQOL instrument gained in surgical exposure of impacted canines. SUBJECTS AND METHODS
Patients scheduled for orthodontic premolar extractions were asked to enroll in a prospective clinical study conducted in 3 oral and maxillofacial surgery clinics beginning in January 2003. Thirty adolescent patients, 18 girls and 12 boys, mean age 14.6 ⫾ 3.8 years, in good general health, were included in this study and underwent orthodontic extractions of 54 premolars; 20 patients had at least 2 simultaneous extractions. On the day of the surgery, after each patient consented to participate in the study, baseline data (age, sex, orthodontist’s name, surgeon’s name, and tooth number) were recorded. The simple and straightforward surgical procedure was performed by 2 authors (G.C. and R.Z.), both senior oral and maxillofacial surgeons, according to a standard protocol that included local anesthesia and tooth extraction. Subsequently, the surgeon recorded details of the surgery, including hour, duration of the surgical procedure, and medication prescribed. Postoperative analgesics were prescribed to all patients, but they were instructed to take them only if required. Two HRQOL instruments4,9 were combined for use in this study (Fig 1). This questionnaire was designed to assess patient perception of recovery in 4 main areas: pain, oral function, general activity, and other symptoms. Pain definitions referred to the severity of pain and the consumption of analgesics. Oral function dealt specifically with swallowing, mouth opening, ability to eat and enjoy ordinary food, and speech. General activity variables targeted the ability to participate in routine daily activities, sleeping, and school attendance. Other symptoms included bleeding, bruising, swelling, food stagnation in surgical sites, a bad taste or bad smell, and general malaise. Patients were not required to return for postsurgery visits but were encouraged to do so if symptoms worsened. For each question, the patients were asked to mark the answer best describing how they felt. The degree of pain was assessed on a visual analog scale of 1 to 10; numbers 1 to 3 referred to slight pain, 4 to 7 meant moderate pain, and 8 to 10 referred to severe pain.
The remaining variables were assessed on a 5-point scale as follows: 1, not at all; 2, very little; 3, some; 4, quite a lot; and 5, severe. The modified HRQOL questionnaire was given to all patients after the surgery. They were asked to complete the questionnaire at the end of each of the 7 postoperative days. In addition, they were telephoned daily to encourage compliance in completing the questionnaire. “Recovery time,” defined as the median number of days needed to reach “slight pain” (1-3 on the 10 point scale) and “not at all/very little” (1 or 2 on the 5 point scale), was assessed for each variable examined. Descriptive statistics were used to summarize separate recovery times in relation to age, sex, time during the day (morning vs afternoon), surgical procedure duration of less than 20 minutes vs 20 minutes or longer, and number of simultaneously extracted teeth. The influence of each predictor variable on the “recovery time” was assessed by a multiple comparisons statistical analysis with the Fisher exact test, with P ⬍.05 taken as the minimum criterion of significance. RESULTS
All patients returned the questionnaire at the 1-week postoperative appointment, for a 100% response rate. Mean duration of the surgical procedure was 19.8 ⫾ 8 minutes. For 12 of the 30 patients, surgery time was more than 20 minutes. On postoperative day (POD) 1, 16.7% reported that pain was severe (score 8-10 or 10) at some point in the day; by POD 2, the number had decreased to 3.3% (Fig 2). Consumption of analgesics declined gradually over the first 3 postoperative days (70%, 13.2%, 3.3%, respectively). Evaluation of oral function, interference in daily activity, and other were reported as the percentages of patients with substantial impairment (scores 4 and 5) follows. On POD 1, difficulty in eating was the most frequently reported symptom (80%), followed by inability to enjoy regular food (40%), swallowing (13.3%), speech (10%), and limitation of mouth opening (10%) (Fig 3). Improvement in most oral functions was evident by POD 2 (inability to enjoy regular food [16.7%], swallowing [3.3%], speech [0%], and limitation in mouth opening [0%]), with the exception of difficulty in eating (20%), which improved only by POD 3. On POD 1, 33.3% of the patients were absent from school, even though only 23.3% reported substantial interference in daily activity (Fig 4). Limitation in daily
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Dear parent/patient, In order to improve the quality of care we provide for our patients, it is important for us to know how the surgical exposure has affected you. We ask you to take a few moments to complete this survey form. Every day you will be telephoned and asked the following questions. Please choose the number that corresponds most closely to your assessment over the past 24 hours. 1. Rate the worst pain you have felt during the past 24 hours on a scale from 1 to 10 1-3 refers to slight pain, 4-7 moderate pain, and 8-10 severe pain For the following questions, please use this system: Not at all=1
Very little=2
A little=3
Quite a lot =4
Severe=5
2. Have you taken any medication to relieve pain today? 3. Has it been difficult to swallow today? 4. Has it been difficult to open your mouth today? 5. Were there any foods you could not eat today? 6. Have you been able to enjoy your food today? 7. Has speech been difficult today? 8. Was it difficult to sleep last night? 9. Have you missed school/work? 10. Has it been difficult to continue your daily activities today? 11. Has there been any swelling today? 12. Has there been bruising today? 13. Has there been bleeding today? 14. Has there been any malaise today? 15. Have you had a bad taste or bad smell in your mouth today? 16. Has there been any food debris in the operation area today? Fig 1. Surgical exposure questionnaire.
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Fig 2. Proportion of patients reporting pain as severe (score 8-10/10) and taking analgesics, according to POD.
Fig 5. Proportion of patients reporting very much swelling, bad taste/smell, bleeding, and food stagnation (score 4-5/5).
Fig 3. Proportion of patients reporting very much difficulty in eating, swallowing, speech, mouth opening, and inability to enjoy regular food (score 4-5/5). Fig 6. Median days needed as ⬙recovery time⬙ for ability to enjoy regular food and for alleviation of bad taste/ smell and food stagnation in ⬍15-year-old vs ⬎15year-old patients.
Fig 4. Proportion of patients reporting absence from school and very much interference with normal activity and sleep (score 4-5/5).
routine declined to 13.3% (4 subjects) by POD 2, resembling absence from school, which reached 20%. Sleep was minimally affected during the entire postsurgical period. The presence of a bad taste or smell was the major distressing postoperative symptom, reportedly the greatest on POD 1 (30%), followed by bleeding (20%), food stagnation (13.3%), and swelling (10%) (Fig 5).
Bruising and malaise were only marginally evident to patients in the recovery period. Recovery time, reflected in ability to eat, required 3 days to reach minimal levels; pain and analgesic consumption required 2 days; within 1 day, all other measures attained minimal levels (Fig 6). No patient returned with aggravated symptoms for a postoperative visit. The influence of predictor variables on “recovery time” was assessed. Recovery was not significantly affected by sex, number of extractions, and duration of treatment. The only predictor variable was age. Patients above the age of 15 years (n ⫽ 12) had slower recoveries compared with patients under 15 years (n ⫽ 18) regarding the ability to enjoy food (POD 3 vs 1, P ⬍.05), taste and smell (POD 3 vs 1, P ⬍.05), and food stagnation (POD 2 vs 1, P ⬍.05) (Fig 7). DISCUSSION
Despite progress in preoperative, operative, and postoperative management, which makes dental treat-
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Fig 7. Median days needed as ⬙recovery time⬙ for each variable studied in entire sample.
ment today easier than ever, many dental patients are still concerned about the operative and postoperative sequelae of various procedures.1 Regardless of the surgical and technical simplicity of orthodontic premolar extractions, the obvious fact that a wound is created makes it reasonable to assume that it will have some adverse influence on several aspects of the HRQOL. Nevertheless, no quantitative study has defined the difficulties that a patient undergoing this procedure can expect in the immediate postoperative days. Our patient sample was young, with a slight preponderance of girls (60%). The results show that most oral functions recovered within 2 days. Pain and analgesic consumption also required 2 days, whereas all other measurements attained minimal levels within 1 day. The questionnaire contained a visual analog scale, which has its own limitations, and its use in young patients has further limitations. Nevertheless, their rapid recoveries demonstrate that pain was not a big concern. We previously used the same HRQOL questionnaire for studying posttreatment recovery after surgical exposure of impacted teeth.11 A comparison of these results with those after surgical exposure of impacted teeth treated with a closed-eruption surgi-
cal-orthodontic technique11 shows that orthodontic premolar extractions lead to a shorter postoperative recovery time (2 vs 3 days). It can be speculated that the fact that there is no need to raise a surgical flap during premolar orthodontic extraction is responsible for the improved recovery. Age (⬎15) was the only predictor variable significantly affecting recovery. It affected the ability to enjoy food, taste and smell, and food stagnation. A recent study of fear of dentistry among Finnish children of various ages found it to be higher among 12- and 15-year-old children than among the younger group.12 Perhaps because teenagers are more aware and perceptive, and have an intensive lifestyle, their expectations about full recovery are higher, when compared with younger children. Therefore, minor interferences for the younger ones become more noteworthy for the teenagers. It is perhaps surprising that 1 premolar extraction vs 2 or more premolar extractions at the same surgical appointment resulted in a similar recovery period. Thus, the concern of many patients and parents that, if more than 1 extraction is performed simultaneously, the child will suffer more, is largely unsupported.
American Journal of Orthodontics and Dentofacial Orthopedics Volume 131, Number 2
CONCLUSIONS
This study describes several variables related to recovery after premolar orthodontic extractions from the patients’ perspectives. Within the limits of this sample, it can be concluded that: 1. Patients should expect, in general, recovery within 2 days after orthodontic premolar extractions. 2. Teenagers over 15 years will experience delayed recoveries. 3. The number of extractions at the same appointment has no effect on posttreatment recovery, supporting the view that performing more than 1 extraction at the same surgical appointment is preferred over dividing the extractions into 2 or more separate sessions. These findings can be used to provide information for the patient, along with the more direct factors of treatment options. This study shows that recovery is extremely rapid, and the practitioner should allay patient concern about the extraction procedure. This should be done with the aim of eliminating it as a factor, in favor of the objective reasons for or against extraction in the orthodontic treatment plan. REFERENCES 1. Peck S, Peck H. Frequency of tooth extraction in orthodontic treatment. Am J Orthod 1979;76:491-6.
Chaushu et al 175
2. Proffit WR. Forty-year review of extraction frequencies at a university orthodontic clinic. Angle Orthod 1994;64:407-14. 3. Klages U, Ulusoy O, Kianifard S, Wehrbein H. Dental trait anxiety and pain sensitivity as predictors of expected and experienced pain in stressful dental procedures. Eur J Oral Sci 2004;112:477-83. 4. Conrad SM, Blakey GH, Shugars DA, Marciani RD, Philips C, White RP Jr. Patients’ perception of recovery after third molar surgery. J Oral Maxillofac Surg 1999;57:1288-94. 5. Morton RP. Quality of life assessment: integral to clinical practice. Clin Otolaryngol 1996;21:1-2. 6. Troidl H, Kusche J, Vestweber KH, Eypasc E, Koeppen L, Bouillon B. Quality of life: an important endpoint both in surgical practice and research. J Chron Dis 1987;40:523-8. 7. Fraser SCA. Quality of life measurement in surgical practice. Br J Surg 1993;80:163-9. 8. Shugars DA, Benson K, White RP Jr, Simpson KN, Bader JD. Developing a measure of patient perception of short-term outcomes of third molar surgery. J Oral Maxillofac Surg 1996;54: 1402-8. 9. Savin J, Ogden GR. Third molar surgery—a preliminary report on aspects affecting quality of life in the early postoperative period. Br J Oral Maxillofac Surg 1997;35:246-53. 10. Reisine ST, Weber J. The effects of temporomandibular joint disorders on patients’ quality of life. Community Dent Health 1989;6:257-70. 11. Chaushu G, Becker A, Zeltser R, Branski S, Chaushu S. Patients’ perceptions of recovery after exposure of impacted teeth with a closed-eruption technique. Am J Orthod Dentofacial Orthop 2004;125:690-6. 12. Rantavuori K, Lahti S, Hausen H, Seppa L, Karkkainen S. Dental fear and oral health and family characteristics of Finnish children. Acta Odontol Scand 2004;62:207-13.
Patients’ perceptions of recovery after routine extraction of healthy premolars Gavriel Chaushu,a Adrian Becker,b Rafael Zeltser,c Naomi Vasker,d Sari Branski,d and Stella Chaushue Tel Aviv and Jerusalem, Israel Introduction: In this prospective study, we evaluated patients’ perceptions of recovery after orthodontic premolar extractions. Methods: Thirty patients (18 girls, 12 boys, mean age 14.6 ⫾ 3.8 years) were given a health-related quality of life questionnaire to be completed each postoperative day (POD) for 7 days. The questionnaire was designed to assess each patient’s perception of recovery: pain, oral function, general activity measures, and other variables. The impact of possible predictor variables, such as age, sex, length of surgical procedure, number of simultaneous extractions, and time during the day, was assessed. Results: Severe pain (16.7%, 3.3%) and consumption of analgesics (70%, 13.2%) declined dramatically from POD 1 to POD 2. Improvements in oral function and other symptoms were evident by POD 2. Absence from school resembled interference in daily activities (POD 2). Age was the most significant predictor variable, with results showing delayed recoveries for patients older than 15 years. The most striking differences were reported for enjoying food (P ⬍.05), taste (P ⬍.05), and food stagnation (P ⬍.05). The number of extractions performed at the same appointment had no affect on posttreatment recovery. Conclusions: This study was designed to provide baseline health-related quality of life information with which to compare other surgical procedures frequently needed in orthodontic treatment, such as removal of third molars and exposure of impacted teeth. Additionally, it provides information for patients and clinicians on postoperative recovery after premolar orthodontic extractions. (Am J Orthod Dentofacial Orthop 2007;131:170-5)
T
ooth extraction is a common treatment consideration in the orthodontic management of dental crowding, or as a tool to compensate for jaw growth discrepancy and to improve facial esthetics. Previous studies reported extremely wide ranges (6.5%-83.5%) in the frequency of extractions in orthodontic treatment.1,2 Premolars are most frequently extracted.2 A possible reason for these differences in attitude toward extractions with often similar diagnoses might be a negative attitude from the patient, the parents, or the practitioner toward removal of teeth in general and in young patients in particular.1 A recent study showed that patients, in general, expected more delayed recovery than actually experia
Senior lecturer and head, Oral and Maxillofacial Surgery Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. Clinical associate professor, Department of Orthodontics, Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel. c Clinical associate professor, Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. d Dental student, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. e Clinical senior lecturer, Department of Orthodontics, Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel. Reprint requests to: Dr G. Chaushu, Oral and Maxillofacial Surgery Unit, Tel Aviv Sourasky Medical Center, 6 Weitzman St, Tel Aviv, Israel, 64239; e-mail, [email protected]. Submitted, May 2005; revised and accepted, June 2005. 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2005.06.024 b
170
enced and suggested that exaggerated negative expectations of postoperative recovery, in a dental patient with a high level of anxiety, might result in a slower recovery.3 Subjects with increased levels of anxiety both expected and experienced more delayed recovery than those with low anxiety levels. These results suggest that patients must be told the postoperative outcome of a proposed procedure, particularly when it pertains to surgery. Patients need to know what they can expect during recovery. The most frequent questions refer to postoperative pain and when the patient can return to work or school. To confront such issues, studies regarding quality of life and health-related quality of life (HRQOL) have been increasingly used in the last decade in all medical disciplines.4-10 There is little room for variation in the operative technique of the surgeon during orthodontic premolar extractions. Although orthodontic premolar extractions might seem routine and everyday occurrences for dental practitioners, they are feared by youngsters, perhaps because of negative representation of the procedure in the media, in conversations with people in general and children in particular, and as a frequent subject in derisive satire. Nevertheless, most information available to both clinicians and patients concerning postoperative recovery was gathered from personal communications between clinicians or 1-time and often highly embellished anecdotal experiences of friends
Chaushu et al 171
American Journal of Orthodontics and Dentofacial Orthopedics Volume 131, Number 2
who had similar procedures. Surprisingly, we found no study in the English literature focusing on either the immediate postoperative period or patients’ perceptions of the various aspects of recovery after orthodontic premolar extractions. Our aim in this prospective study was to assess patients’ perceptions of immediate postoperative recovery after orthodontic premolar extractions in the light of the established experience of the HRQOL instrument gained in surgical exposure of impacted canines. SUBJECTS AND METHODS
Patients scheduled for orthodontic premolar extractions were asked to enroll in a prospective clinical study conducted in 3 oral and maxillofacial surgery clinics beginning in January 2003. Thirty adolescent patients, 18 girls and 12 boys, mean age 14.6 ⫾ 3.8 years, in good general health, were included in this study and underwent orthodontic extractions of 54 premolars; 20 patients had at least 2 simultaneous extractions. On the day of the surgery, after each patient consented to participate in the study, baseline data (age, sex, orthodontist’s name, surgeon’s name, and tooth number) were recorded. The simple and straightforward surgical procedure was performed by 2 authors (G.C. and R.Z.), both senior oral and maxillofacial surgeons, according to a standard protocol that included local anesthesia and tooth extraction. Subsequently, the surgeon recorded details of the surgery, including hour, duration of the surgical procedure, and medication prescribed. Postoperative analgesics were prescribed to all patients, but they were instructed to take them only if required. Two HRQOL instruments4,9 were combined for use in this study (Fig 1). This questionnaire was designed to assess patient perception of recovery in 4 main areas: pain, oral function, general activity, and other symptoms. Pain definitions referred to the severity of pain and the consumption of analgesics. Oral function dealt specifically with swallowing, mouth opening, ability to eat and enjoy ordinary food, and speech. General activity variables targeted the ability to participate in routine daily activities, sleeping, and school attendance. Other symptoms included bleeding, bruising, swelling, food stagnation in surgical sites, a bad taste or bad smell, and general malaise. Patients were not required to return for postsurgery visits but were encouraged to do so if symptoms worsened. For each question, the patients were asked to mark the answer best describing how they felt. The degree of pain was assessed on a visual analog scale of 1 to 10; numbers 1 to 3 referred to slight pain, 4 to 7 meant moderate pain, and 8 to 10 referred to severe pain.
The remaining variables were assessed on a 5-point scale as follows: 1, not at all; 2, very little; 3, some; 4, quite a lot; and 5, severe. The modified HRQOL questionnaire was given to all patients after the surgery. They were asked to complete the questionnaire at the end of each of the 7 postoperative days. In addition, they were telephoned daily to encourage compliance in completing the questionnaire. “Recovery time,” defined as the median number of days needed to reach “slight pain” (1-3 on the 10 point scale) and “not at all/very little” (1 or 2 on the 5 point scale), was assessed for each variable examined. Descriptive statistics were used to summarize separate recovery times in relation to age, sex, time during the day (morning vs afternoon), surgical procedure duration of less than 20 minutes vs 20 minutes or longer, and number of simultaneously extracted teeth. The influence of each predictor variable on the “recovery time” was assessed by a multiple comparisons statistical analysis with the Fisher exact test, with P ⬍.05 taken as the minimum criterion of significance. RESULTS
All patients returned the questionnaire at the 1-week postoperative appointment, for a 100% response rate. Mean duration of the surgical procedure was 19.8 ⫾ 8 minutes. For 12 of the 30 patients, surgery time was more than 20 minutes. On postoperative day (POD) 1, 16.7% reported that pain was severe (score 8-10 or 10) at some point in the day; by POD 2, the number had decreased to 3.3% (Fig 2). Consumption of analgesics declined gradually over the first 3 postoperative days (70%, 13.2%, 3.3%, respectively). Evaluation of oral function, interference in daily activity, and other were reported as the percentages of patients with substantial impairment (scores 4 and 5) follows. On POD 1, difficulty in eating was the most frequently reported symptom (80%), followed by inability to enjoy regular food (40%), swallowing (13.3%), speech (10%), and limitation of mouth opening (10%) (Fig 3). Improvement in most oral functions was evident by POD 2 (inability to enjoy regular food [16.7%], swallowing [3.3%], speech [0%], and limitation in mouth opening [0%]), with the exception of difficulty in eating (20%), which improved only by POD 3. On POD 1, 33.3% of the patients were absent from school, even though only 23.3% reported substantial interference in daily activity (Fig 4). Limitation in daily
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Dear parent/patient, In order to improve the quality of care we provide for our patients, it is important for us to know how the surgical exposure has affected you. We ask you to take a few moments to complete this survey form. Every day you will be telephoned and asked the following questions. Please choose the number that corresponds most closely to your assessment over the past 24 hours. 1. Rate the worst pain you have felt during the past 24 hours on a scale from 1 to 10 1-3 refers to slight pain, 4-7 moderate pain, and 8-10 severe pain For the following questions, please use this system: Not at all=1
Very little=2
A little=3
Quite a lot =4
Severe=5
2. Have you taken any medication to relieve pain today? 3. Has it been difficult to swallow today? 4. Has it been difficult to open your mouth today? 5. Were there any foods you could not eat today? 6. Have you been able to enjoy your food today? 7. Has speech been difficult today? 8. Was it difficult to sleep last night? 9. Have you missed school/work? 10. Has it been difficult to continue your daily activities today? 11. Has there been any swelling today? 12. Has there been bruising today? 13. Has there been bleeding today? 14. Has there been any malaise today? 15. Have you had a bad taste or bad smell in your mouth today? 16. Has there been any food debris in the operation area today? Fig 1. Surgical exposure questionnaire.
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Fig 2. Proportion of patients reporting pain as severe (score 8-10/10) and taking analgesics, according to POD.
Fig 5. Proportion of patients reporting very much swelling, bad taste/smell, bleeding, and food stagnation (score 4-5/5).
Fig 3. Proportion of patients reporting very much difficulty in eating, swallowing, speech, mouth opening, and inability to enjoy regular food (score 4-5/5). Fig 6. Median days needed as ⬙recovery time⬙ for ability to enjoy regular food and for alleviation of bad taste/ smell and food stagnation in ⬍15-year-old vs ⬎15year-old patients.
Fig 4. Proportion of patients reporting absence from school and very much interference with normal activity and sleep (score 4-5/5).
routine declined to 13.3% (4 subjects) by POD 2, resembling absence from school, which reached 20%. Sleep was minimally affected during the entire postsurgical period. The presence of a bad taste or smell was the major distressing postoperative symptom, reportedly the greatest on POD 1 (30%), followed by bleeding (20%), food stagnation (13.3%), and swelling (10%) (Fig 5).
Bruising and malaise were only marginally evident to patients in the recovery period. Recovery time, reflected in ability to eat, required 3 days to reach minimal levels; pain and analgesic consumption required 2 days; within 1 day, all other measures attained minimal levels (Fig 6). No patient returned with aggravated symptoms for a postoperative visit. The influence of predictor variables on “recovery time” was assessed. Recovery was not significantly affected by sex, number of extractions, and duration of treatment. The only predictor variable was age. Patients above the age of 15 years (n ⫽ 12) had slower recoveries compared with patients under 15 years (n ⫽ 18) regarding the ability to enjoy food (POD 3 vs 1, P ⬍.05), taste and smell (POD 3 vs 1, P ⬍.05), and food stagnation (POD 2 vs 1, P ⬍.05) (Fig 7). DISCUSSION
Despite progress in preoperative, operative, and postoperative management, which makes dental treat-
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Fig 7. Median days needed as ⬙recovery time⬙ for each variable studied in entire sample.
ment today easier than ever, many dental patients are still concerned about the operative and postoperative sequelae of various procedures.1 Regardless of the surgical and technical simplicity of orthodontic premolar extractions, the obvious fact that a wound is created makes it reasonable to assume that it will have some adverse influence on several aspects of the HRQOL. Nevertheless, no quantitative study has defined the difficulties that a patient undergoing this procedure can expect in the immediate postoperative days. Our patient sample was young, with a slight preponderance of girls (60%). The results show that most oral functions recovered within 2 days. Pain and analgesic consumption also required 2 days, whereas all other measurements attained minimal levels within 1 day. The questionnaire contained a visual analog scale, which has its own limitations, and its use in young patients has further limitations. Nevertheless, their rapid recoveries demonstrate that pain was not a big concern. We previously used the same HRQOL questionnaire for studying posttreatment recovery after surgical exposure of impacted teeth.11 A comparison of these results with those after surgical exposure of impacted teeth treated with a closed-eruption surgi-
cal-orthodontic technique11 shows that orthodontic premolar extractions lead to a shorter postoperative recovery time (2 vs 3 days). It can be speculated that the fact that there is no need to raise a surgical flap during premolar orthodontic extraction is responsible for the improved recovery. Age (⬎15) was the only predictor variable significantly affecting recovery. It affected the ability to enjoy food, taste and smell, and food stagnation. A recent study of fear of dentistry among Finnish children of various ages found it to be higher among 12- and 15-year-old children than among the younger group.12 Perhaps because teenagers are more aware and perceptive, and have an intensive lifestyle, their expectations about full recovery are higher, when compared with younger children. Therefore, minor interferences for the younger ones become more noteworthy for the teenagers. It is perhaps surprising that 1 premolar extraction vs 2 or more premolar extractions at the same surgical appointment resulted in a similar recovery period. Thus, the concern of many patients and parents that, if more than 1 extraction is performed simultaneously, the child will suffer more, is largely unsupported.
American Journal of Orthodontics and Dentofacial Orthopedics Volume 131, Number 2
CONCLUSIONS
This study describes several variables related to recovery after premolar orthodontic extractions from the patients’ perspectives. Within the limits of this sample, it can be concluded that: 1. Patients should expect, in general, recovery within 2 days after orthodontic premolar extractions. 2. Teenagers over 15 years will experience delayed recoveries. 3. The number of extractions at the same appointment has no effect on posttreatment recovery, supporting the view that performing more than 1 extraction at the same surgical appointment is preferred over dividing the extractions into 2 or more separate sessions. These findings can be used to provide information for the patient, along with the more direct factors of treatment options. This study shows that recovery is extremely rapid, and the practitioner should allay patient concern about the extraction procedure. This should be done with the aim of eliminating it as a factor, in favor of the objective reasons for or against extraction in the orthodontic treatment plan. REFERENCES 1. Peck S, Peck H. Frequency of tooth extraction in orthodontic treatment. Am J Orthod 1979;76:491-6.
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