DENTOALVEOLAR SURGERY
Effect of Quality of Life Measures on the Decision to Remove Third Molars in Subjects With Mild Pericoronitis Symptoms Dana T. Tang, DDS,* Ceib Phillips, PhD, MPH,y William R. Proffit, DDS, PhD,z Lorne D. Koroluk, DMD, MSD, MS,x and Raymond P. White, Jr, DDS, PhDk Purpose:
To assess how quality of life (QoL) measures affect the decision for third molar (3M) removal in patients with mild symptoms of pericoronitis.
Patients and Methods:
Healthy subjects, aged 18 to 35 years, with mild symptoms of pericoronitis were enrolled in an institutional review board–approved study. The demographic, clinical, and QoL data were collected at enrollment. The subjects voluntarily scheduled surgery for 3M removal. The principal outcome variable was their decision to undergo or not undergo surgery within 6 months of enrollment. The possible predictor variables in a multivariate logistic regression analysis were the demographic characteristics, dental insurance, and QoL measures.
The mean age of the 113 subjects was 23.2 3.8 years. Of the 113 subjects, 79 elected to undergo 3M removal within 6 months of enrollment (removed group) and 34 elected to retain their 3M at 6 months after enrollment (retained group). A significantly greater proportion of the removed group were white (58% vs 35%; P = .03) and reported having at least ‘‘a little trouble’’ with opening their mouths (38% vs 18%; P = .04) and taking part in social life (27% vs 6%; P = .01). The multivariate logistic regression model suggested the odds of electing 3M removal within 6 months of enrollment were greater for those who were white (odds ratio [OR] 2.69, 95% confidence interval [CI] 1.14 to 6.32) and those who had at least ‘‘a little trouble’’ with interactions in their social life (OR 3.22, 95% CI 1.08 to 9.58). Results:
Conclusions: In subjects with mild pericoronitis symptoms, experiencing problems with oral function and lifestyle, factors not often considered by clinicians, were significantly associated with subjects’ decision for early 3M removal. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-9, 2014
Pericoronitis is a chronic periodontal inflammatory condition associated with a partially or fully erupted tooth, most often a mandibular third molar (3M).1,2 This symptomatic condition will be commonly diagnosed in individuals aged 16 to 30 years and has a wide range of symptoms, including pain and swelling. The more severe clinical signs include purulence, trismus,
dysphagia, enlarged lymph nodes, and fever.1 Although an acute pericoronitis episode could last for only a few days, recurrences will typically follow, with a remission period of 7 to 15 months.1 Vent€a et al3 evaluated the history of patients with symptomatic 3Ms and found that 51% of reported patients had had 1 previous episode with the same tooth. The prevalence of pericoronitis
Received from University of North Carolina School of Dentistry,
Surgeons, and the Department of Oral and Maxillofacial Surgery,
Chapel Hill, NC.
University of North Carolina School of Dentistry.
*Senior Resident, Department of Orthodontics.
Address correspondence and reprint requests to Dr White:
yProfessor, Department of Orthodontics. zKenan Distinguished Professor, Department of Orthodontics.
Department of Oral and Maxillofacial Surgery, University of North Carolina School of Dentistry, Chapel Hill, NC 27599-7450; e-mail:
xAssociate Professor, Departments of Orthodontics and Pediatric
[email protected]
Dentistry.
Received December 13 2013
kDalton L. McMichael Distinguished Professor, Department of
Accepted March 24 2014 Ó 2014 American Association of Oral and Maxillofacial Surgeons
Oral and Maxillofacial Surgery. The present study was supported by the Oral and Maxillofacial
0278-2391/14/00335-8$36.00/0
Surgery Foundation, American Association of Oral and Maxillofacial
http://dx.doi.org/10.1016/j.joms.2014.03.022
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PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
has not been studied for the US population. Berge4 has reported the only population data for pericoronitis, with an approximately 9% prevalence, from a Norwegian population using reports from general dentists. Estimates from the available data have varied, ranging from 2 to 9%.4-6 Currently, the most effective treatment of pericoronitis is removal of the symptomatic tooth.7 The most prevalent 3M symptom is pain, usually associated with pericoronitis. Berge and Boe8 found, in a random sample of 176 general dentists, that pericoronitis contributed to 43% of 3M problems. Furthermore, pericoronitis has been the most commonly reported reason for 3M removal in young adults and older age groups.9 For example, in a cohort of patients 35 years or older, 41% reported pericoronitis as the reason for electing to have their 3Ms removed, followed by periodontal problems at 25%.9 In addition to symptoms of pain, pericoronitis also has an effect on one’s quality of life (QoL), including lifestyle and oral function.2 McNutt et al2 assessed the QoL of 57 subjects with mild symptoms of pericoronitis and found that 68% reported the worst pain they had experienced in the week before enrollment to be at least moderate in severity. Almost one quarter of the subjects reported oral function problems and had ‘‘quite a bit/lots’’ of difficulty with eating.2 Also, 19% had ‘‘quite a bit/lots’’ of difficulty with chewing.2 Removal of 3Ms will improve the QoL measures in patients with pericoronitis symptoms.10,11 McGrath et al10 assessed the QoL measures in 69 subjects with pericoronitis. At 6 months after having 1 mandibular 3M removed, the QoL had improved as measured using the 14-item Oral Health Impact questionnaire.10 Similarly, Bradshaw et al11 evaluated 60 subjects who had presented with mild symptoms of pericoronitis and elected to have all 3Ms removed. At a median of 7.7 months after surgery, significant improvements in the QoL measures were reported. For example, at enrollment, 15% of the subjects had reported their pain intensity in the week before enrollment as ‘ nothing,’ ‘ faint,’’ or ‘ very weak.’’ This outcome had improved to 97% at follow-up. Regarding oral function, 42% had reported having no difficulty with eating in the week before enrollment, and this had increased to 95% at follow-up.11 Although studies have clearly shown that pericoronitis negatively affects the QoL and that removal of the affected teeth can improve QoL, not everyone with these 3M problems will elect to have their 3Ms removed.12,13 In a longitudinal study by Vent€a et al,13 one third of the subjects had 3M symptoms, and most of the subjects with symptoms, 87%, but not all, underwent 3M removal.13 The question of which factors, in addition to the symptoms of pain, influence the decision to have 3Ms removed in subjects with pericoronitis remains.
The present study focused on the demographic characteristics, availability of dental insurance, and QoL measures as possible explanatory variables for a patient with mild pericoronitis symptoms to decide to remove or retain 3Ms within 6 months after enrollment.
Patients and Methods The subjects were enrolled in a study designed to better understand the clinical signs and symptoms of mild pericoronitis affecting mandibular 3Ms as they relate to oral and systemic inflammation. The subjects were recruited at a single academic clinical center, the University of North Carolina, for an institutional review board–approved, prospective, exploratory clinical study. The present study was registered with ClinicalTrials.gov (identifier NCT 01882270). All data from those enrolled from 2006 to 2012 with information about whether their 3Ms had been removed or retained at 6 months after enrollment were included in the analyses. Those who had undergone 3M removal were seen for follow-up at least 3 months after surgery.11 All those who had not undergone 3M removal were followed up for at least 1 year after enrollment. The inclusion criteria for the study specified that the subjects be aged 18 to 35 years, have a health risk assessment level of I or II according to the American Society of Anesthesiologists’ classification, and have mild signs or symptoms of pericoronitis, including spontaneous pain, purulence or drainage, and/or localized swelling, that affected at least 1 mandibular 3M. Those with severe signs or symptoms of pericoronitis, such as limited mouth opening, dysphagia, a temperature greater than 101 F, facial swelling or cellulitis, or severe uncontrolled discomfort were excluded. Additionally, those with a medical condition contraindicating periodontal probing, an acute illness, a body mass index (BMI) greater than 29 kg/m2, a history of antibiotic treatment within the previous 2 months, or generalized periodontal disease (Class IV according to the American Academy of Periodontology index) and those who used tobacco were excluded. Once consent to participate in the present study had been obtained, the demographic, clinical, and QoL data were collected from each subject. To assess the effect of mild pericoronitis on QoL in the previous week, at enrollment, the subjects were asked to complete the Health-Related QoL instrument, which includes 2 items in the pain domain and 4 each in the domains of lifestyle and oral function. The instrument was developed by Shugars et al14 specifically for 3M problems. The subjects were asked to report how their oral function and lifestyle had been affected in the week before enrollment using a 5-point Likert-type scale, ranging from ‘‘no trouble’’ (score 1) to ‘‘lots of trouble’’ (score 5). Because pain is the predominantly
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TANG ET AL
reported symptom of pericoronitis, the subjects were asked to assess their pain in the week before enrollment using a 7-point Likert-type scale. The 7-point scale for pain extended from ‘‘no pain’’ (score 1) to ‘‘the worst pain imaginable’’ (score 7). The items were categorized according to content into specific domains: oral function, lifestyle, and pain. The pain items were stratified as the worst and average pain. The thresholds of pain severity were reported as ‘‘no pain’’ (score 1), ‘‘little to moderate pain’’ (score 2 to 4), and ‘‘severe pain’’ (score 5 to 7). Oral function included the ability to eat, chew, talk, and open one’s mouth. Lifestyle included the ability to sleep, perform a daily routine, take part in social life, and participate in sports or hobbies. For the analyses, the thresholds of oral function and lifestyle effect were ‘‘no trouble’’ (score 1), ‘‘a little trouble’’ (score 2), and ‘‘more than a little trouble’’ (score 3 to 5), with the latter including the responses ‘‘some,’’ ‘‘quite a bit,’’ and ‘‘lots of trouble.’’ Gross debris was removed from the symptomatic 3Ms at enrollment, and analgesic medications were prescribed as needed for pain. The subjects were given the recommendation that their 3Ms should be removed as the most predictable treatment of the condition; however, no timetable for surgery was prescribed. The subjects voluntarily scheduled the surgery in consultation with their dentist. In accordance with the report from Bradshaw et al11 that had assessed QoL outcomes after surgery in subjects with mild pericoronitis, our subjects were divided into 2 groups: those who undergone surgery within 6 months of enrollment (removed group) and those who had not (retained group). The principal outcome variable for the analyses in the present study was the decision to undergo or not undergo surgery within 6 months of enrollment. The principal predictors or explanatory variables were the subjects’ reported QoL in the domains of oral function, lifestyle, and pain at enrollment. Other possible contributing variables were the demographic data (age, gender, ethnicity, and highest educational level) and the availability of dental insurance that would at least partially contribute to covering the surgical charges. The data entry and data management protocols were used as described previously by White et al.15 For the subjects in the removed and retained groups, the demographic characteristics and availability of insurance were compared using c2 analyses. The QoL measures were compared using Cochran-Mantel-Haenszel row mean score statistics. A logistic regression analysis using a 2-step forward selection approach was used to identify the QoL variables that contributed to the subject’s decision. The first model included only the demographic and availability of dental insurance variables. Statistically significant variables from the first model
were forced into the second forward selection model that included the QoL measures. The analyses were performed using Statistical Analysis Systems, version 9.2 (SAS Institute, Cary, NC). Significance was set at P < .05 for all analyses.
Results A total of 113 subjects with mild symptoms of pericoronitis were enrolled during a 6-year period from 2006 to 2012. Most subjects eventually elected 3M removal; only a few subjects retained their 3Ms for the entire study period, which amounted to at least 1 year (Fig 1). The mean age of the subjects at enrollment was 23.2 3.8 years. More subjects were female and white (56% and 51%, respectively; Table 1). Also, most subjects were well educated, with 92% reported having at least some college education. Less than one half of all subjects (41%) had dental insurance. The subjects in the removed category were more likely to be 23 years old or younger, but this pattern was not statistically significant (P = .11). The mean age of the 79 subjects at enrollment in the removed group was 22.8 3.5 years, and the mean age of the 34 subjects at enrollment in the retained group was 23.9 4.2 years. Differences in ethnicity existed between the 2 groups, with significantly more white subjects undergoing surgery within 6 months of enrollment compared with those delaying surgery later than 6 months or retaining their 3Ms (58% and 35%, respectively; P = .03). Additionally, more African-Americans were in the retained group (35%) than in the removed group (18%). Although only 41% of all subjects had dental insurance, more subjects in the removed group reported having dental insurance (47%) compared with the retained group (29%; P = .09; Table 1). A total of 79 subjects elected 3M removal within 6 months of enrollment, with a mean interval of 2.5 1.6 months after enrollment (Fig 1). Thirty-four subjects retained their 3Ms at 6 months after enrollment. Of these 34 subjects, 14 eventually underwent 3M removal; 9 had their 3Ms removed more than 1 year after enrollment. One half of the 34 subjects who retained their 3Ms at 6 months after enrollment (15% of the 113 subjects enrolled), still had their 3Ms at the last follow-up visit, at least 1 year after enrollment. The QoL measures in the oral function domain tended to be greater in the week before enrollment for the removed group than for the retained group. Significantly more subjects in the removed group (38%) had had at least ‘‘a little trouble’’ with mouth opening than in the retained group (18%; P = .04; Fig 2, Table 2). Although not statistically significant, a greater proportion of subjects in the removed group also reported higher scores or ‘‘more than a little
4
PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
FIGURE 1. Flow diagram of study participants enrolled with mild symptoms of pericoronitis. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
trouble,’’ for other oral function items than did the retained group (Fig 2, Table 2). For example, 38% of subjects in the removed group reported ‘‘more than a little trouble’’ with chewing compared with 33% in the retained group.
In the lifestyle domain, significantly more subjects in the removed group (27%) had at least ‘‘a little trouble’’ taking part in social life compared with the subjects in the retained group (6%; P = .01, Fig 3, Table 2). The difficulty with mouth opening and the
Table 1. DEMOGRAPHIC CHARACTERISTICS OF ALL SUBJECTS AT ENROLLMENT (N = 113)
Characteristic Age (yr) #23 >23 Gender Female Male Ethnicity White Nonwhite African-American Asian Hispanic Other Dental insurancek No Yes
Total (N = 113)
Third Molars Removed* (n = 79)
Third Molars Retainedy (n = 34)
66 (58.4) 47 (41.6)
50 (63.2) 29 (36.7)
16 (47.1) 18 (52.9)
63 (55.8) 50 (44.3)
43 (54.4) 36 (45.6)
20 (58.8) 14 (41.2)
58 (51.3) 55 (48.7) 26 (23.0) 14 (12.4) 6 (5.3) 9 (8.0)
46 (58.2) 33 (41.8) 14 (17.7) 9 (11.4) 6 (7.6) 4 (5.1)
12 (35.3) 22 (64.7) 12 (35.3) 5 (14.7) 0 (0.0) 5 (14.7)
65 (58.6) 46 (41.4)
41 (53.3) 36 (46.8)
24 (70.6) 10 (29.4)
P Valuez .11
.67 .03x
.09
Data presented as n (%); percentage totals might not equal 100% because percentages were rounded to the nearest tenth decimal place. * Removed within 6 months of enrollment. y Retained at 6 months after enrollment. z P values computed using c2 test. x P < .05. k Data missing for $1 subjects. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
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TANG ET AL
FIGURE 2. Comparison of the distribution of subjects reporting difficulty with oral function in the week before enrollment for the removed (n = 79) and retained (n = 34) groups. The removed group consisted of subjects who had elected third molar removal within 6 months of enrollment. The retained group consisted of subjects who had retained their third molars at 6 months after enrollment. The percentage totals might not equal 100% because the percentages were rounded to the nearest whole number. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
effect on social interactions were significantly correlated (rs = 0.49; P < .0001). Compared with the oral function items, the proportion of subjects in the removed and retained groups who reported at least ‘‘a little trouble’’ in the lifestyle items tended to be smaller. However, more subjects in the removed group than in the retained group reported at least ‘‘a little trouble’’ in all the lifestyle measures. The mean scores for the worst and average pain in the week before enrollment were at the lower end of the 7-point Likert-type scale, compatible with the enrollment criteria for the study. The mean worst and average pain levels were not significantly different between the removed and retained groups (P = .30 and P = .59, respectively; data not shown). More subjects had reported their worst pain levels in the week before enrollment as severe in the removed group (27%) than in the retained group (15%; P = .23; Fig 4, Table 2). Few subjects in both groups reported their average pain as severe. The multivariate logistic regression models suggested 2 factors that increased the odds of early surgery: ethnicity and an item in the lifestyle domain, the amount of difficulty the subjects had with interactions in their social life. Both were associated with the subjects’ decision to have the 3Ms removed within 6 months of enrollment. Whites were more
likely to have their 3Ms removed within 6 months of enrollment than were nonwhites (odds ratio [OR] 2.69, 95% confidence Interval [CI] 1.14 to 6.32). Having at least ‘‘a little trouble’’ with participating in social life at enrollment compared with ‘‘no trouble’’ increased the chances of a decision for early surgery (OR 3.22, 95% CI 1.08 to 9.58). Those subjects with ‘‘more than a little trouble’’ participating in social life compared with ‘‘no trouble’’ were more likely (OR 10.33, 95% CI 1.16 to 91.86) to have had their 3Ms removed within 6 months.
Discussion The data we have reported suggest that for subjects with symptomatic 3Ms and pain scores on the lower end of a 7-point Likert-type scale, factors other than pain will also influence an individual’s decision for early surgery. On average, our study subjects who elected surgery did so within 3 months after enrollment. The QoL measures for the oral function and lifestyle domains were significantly associated with the decision for early 3M removal. Although 15% of the 113 enrolled subjects retained their 3Ms at the longest follow-up point, the odds of electing early surgery were 3 times greater for those whose lifestyle was
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PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
Table 2. SUBJECTS’ QUALITY OF LIFE MEASURES IN WEEK BEFORE ENROLLMENT
Quality of Life Measure Trouble with eating No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with chewingx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with talkingx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with mouth opening No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with sleepingx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble performing daily routine No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with taking part in social life No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with participating in sportsx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Worst pain No pain (score 1) Little to moderate pain (score 2-4) Severe pain (score 5-7) Average pain No pain (score 1) Little to moderate pain (score 2-4) Severe pain (score 5-7)
Total (n=113)
Third Molars Removed (n=79)*
Third Molars Retained (n=34)y
45 (39.8) 24 (21.2) 44 (38.9)
32 (40.5) 16 (20.3) 31 (39.2)
13 (38.2) 8 (23.5) 13 (38.2)
41 (36.6) 30 (26.8) 41 (36.6)
29 (36.7) 20 (25.3) 30 (38.0)
12 (36.4) 10 (30.3) 11 (33.3)
94 (83.9) 15 (13.4) 3 (2.7)
63 (79.8) 14 (17.7) 2 (2.5)
31 (93.9) 1 (3.0) 1 (3.0)
77 (68.1) 24 (21.2) 12 (10.6)
49 (62.0) 20 (25.3) 10 (12.7)
28 (82.4) 4 (11.8) 2 (5.9)
79 (70.5) 19 (17.0) 14 (12.5)
55 (70.5) 12 (15.4) 11 (14.1)
24 (70.6) 7 (20.6) 3 (8.8)
77 (68.1) 24 (21.2) 12 (10.6)
51 (64.6) 17 (21.5) 11 (13.9)
26 (76.5) 7 (20.6) 1 (2.9)
90 (79.7) 14 (12.4) 9 (8.0)
58 (73.4) 13 (16.5) 8 (10.1)
32 (94.1) 1 (2.9) 1 (2.9)
97 (86.6) 9 (8.0) 6 (5.4)
67 (85.9) 7 (9.0) 4 (5.1)
30 (88.2) 2 (5.9) 2 (5.9)
12 (10.6) 75 (66.4) 26 (23.0)
8 (10.1) 50 (63.3) 21 (26.6)
4 (11.8) 25 (73.5) 5 (14.7)
27 (23.9) 80 (70.8) 6 (5.3)
18 (22.8) 56 (70.9) 5 (6.3)
9 (26.5) 24 (70.6) 1 (2.9)
P Valuez .94
.81
.07
.04k
.87
.15
.01k
.76
.23
.52
Data presented as n (%); percentage totals might not total 100% because percentages were rounded to the nearest tenth decimal place (n=113). * Within 6 months of enrollment. y Retained at 6 months after enrollment. z P values computed using Cochran Mantel-Haenszel row mean score statistics. x Data missing for one subject. k P < .05. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
compromised with at least ‘‘a little trouble’’ compared with those who reported no such problems. QoL issues were not the only factors associated with the decision for early surgery. The odds were more than 2.5 times more likely that whites compared
with the other enrolled ethnic groups would elect early surgery. We have no data to explain these differences. Although fewer than one half of the subjects had dental insurance that might have reduced some of the surgical charges, those with dental
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TANG ET AL
FIGURE 3. Comparison of the distribution of subjects reporting difficulty with lifestyle in the week before enrollment for the removed (n = 79) and retained (n = 34) groups. The removed group consisted of subjects who had elected third molar removal within 6 months of enrollment. The retained group consisted of subjects who had retained their third molars at 6 months after enrollment. The percentage totals might not equal 100% because the percentages were rounded to the nearest whole number. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
insurance tended to elect to have their 3Ms removed early. This suggests that financial assistance with the charges for surgery could play a role in the decision for 3M removal. Although we have reported that additional factors might be influential, most clinicians will assume correctly that the pain resulting from localized inflammation is a major factor involved in 3M removal decisions. All subjects who had their 3Ms removed reported pain as the primary, but not the sole, reason for electing surgery. Clinicians readily associate pericoronitis with recurring painful episodes. Vent€a et al3 evaluated the history of patients who presented with symptomatic 3Ms and found that one half had had 1 previous episode with the same tooth, more than one third had had 2 or more episodes with the same tooth, and about two thirds had had symptoms with another 3M. Furthermore, White et al15 evaluated the recovery after 3M surgery and found that previous symptoms of pain or swelling played a role in the decision for surgery in 37% of the subjects. Also, 78% reported they had elected surgery to avoid future problems.15 Our definition of ‘‘early’’ versus ‘‘late’’ surgery was based on the report by Bradshaw et al,11 in which subjects averaged less than 3 months from enrollment to surgery. A doubling of this period as the threshold for early surgery was somewhat arbitrary; however,
gave individuals sufficient time to elect surgery, taking into account daily demands, such as vacations, holidays, and examinations. For the removed group, the average interval to surgery was 2.5 months. It is important to add that 82% of the subjects with mild symptoms of pericoronitis who enrolled in our study eventually underwent 3M removal; only 8% underwent surgery more than 1 year after enrollment. Most subjects in our study elected surgery relatively quickly after enrollment. Blakey et al16 reported that for subjects with asymptomatic 3Ms, the median interval from enrollment to surgery was 2.4 years. This was 12 times longer than the 2.5 -month period for the ‘‘early’’ group of subjects in our study. Our study had limitations. Our sample consisted of young, well-educated individuals, typical of patients frequenting an academic center in a university community and not representative of the US population who might have this condition. Our study excluded subjects with severe symptoms of pericoronitis, because these individuals could not ethically be asked to retain their 3Ms in a longitudinal study without active treatment. The inflammatory response to pathogens might differ for those with more severe symptoms of pericoronitis.17 Also, more severe pericoronitis symptoms could have a greater effect on QoL and the resulting decision and timing for 3M removal in affected individuals.17 Our study excluded
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PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
FIGURE 4. Comparison of the distribution of subjects reporting pain in the week before enrollment for the removed (n = 79) and retained (n = 34) groups. The removed group consisted of subjects who had elected third molar removal within 6 months of enrollment. The retained group consisted of subjects who had retained their third molars at 6 months after enrollment. The percentage totals might not equal 100% because the percentages were rounded to the nearest whole number. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
subjects with medical conditions contraindicating periodontal probing, antibiotic use, or generalized periodontal disease. In addition, those with a BMI greater than 29 kg/m2 or who used tobacco were excluded because of the possible circulating inflammatory mediators from these conditions affecting the oral inflammatory response.18,19 Although the number of subjects in our study was adequate to demonstrate differences based on the decision for early or late surgery, the small numbers of subjects with lifestyle or oral function Likert scores of 3 to 5 of a total of 5 limited the conclusions from the statistical analyses and the generalizability to other populations. Future studies, to provide data more representative of the entire US population, should include a larger number of subjects and those who might not be as healthy. However, interested clinical investigators should be cautioned that, overall, fewer than 10% of young adults might have pericoronitis symptoms, making enrollment of an adequate numbers of subjects protracted.4-6 This outcome was reflected in the 6-year period required to enroll our subjects for the present study. How might clinicians use this data? Clinicians should not assume that only the pain symptoms will be important to a patient’s decision for surgical removal of symptomatic 3Ms. Additional information
on how QoL might have been affected should be documented. Making patients aware of the recurring nature of the pain and the other QoL issues should be a part of the consultation process for a patient and the information shared with referring clinicians. Furthermore, considerations of how pericoronitis affects QoL should lead to alterations in the practice guidelines for the management of 3Ms. Acknowledgments The authors would like to thank the volunteers who participated in our study, Ms Debora Price for her assistance in managing the data in this project, and Ms Tiffany Hambright for her assistance as the clinical coordinator.
References 1. Kay LW: Investigations into the nature of pericoronitis. Br J Oral Surg 3:188, 1966 2. McNutt M, Partrick M, Shugars DA, et al: Impact of symptomatic pericoronitis on health-related quality of life. J Oral Maxillofac Surg 66:2482, 2008 3. Vent€a I, Turtola L, Murtomaa H, Ylipaavalniemi P: Third molars as an acute problem in Finnish university students. Oral Surg Oral Med Oral Pathol 76:135, 1993 4. Berge TI: Third molars in Norwegian general dental practice. Acta Odontol Scand 50:17, 1992 5. Leone SA, Edenfield MJ: Third molars and acute pericoronitis: A military problem. Mil Med 152:146, 1987
TANG ET AL 6. Rajasuo A, Murtomaa H, Meurman JH: Comparison of the clinical status of third molars in young men in 1949 and in 1990. Oral Surg Oral Med Oral Pathol 76:694, 1993 7. Blakey GH, White RP Jr, Offenbacher S, et al: Clinical/biological outcomes of treatment for pericoronitis. J Oral Maxillofac Surg 54:1150, 1996 8. Berge TI, Boe OE: Symptoms and lesions associated with retained or partially erupted third molars: Some variables of third-molar surgery in Norwegian general practice. Acta Odontol Scand 51:115, 1993 9. Bruce RA, Frederickson GC, Small GS: Age of patients and morbidity associated with mandibular third molar surgery. J Am Dent Assoc 101:240, 1980 10. McGrath C, Comfort MB, Lo EC, Luo Y: Can third molar surgery improve quality of life? A 6-month cohort study. J Oral Maxillofac Surg 61:759, 2003 11. Bradshaw S, Faulk J, Blakey GH, et al: Quality of life outcomes after third molar removal in subjects with minor symptoms of pericoronitis. J Oral Maxillofac Surg 70:2494, 2012 12. Kinard BE, Dodson TB: Most patients with asymptomatic, disease-free third molars elect extraction over retention as their preferred treatment. J Oral Maxillofac Surg 68:2935, 2010
9 13. Vent€a I, Ylipaavalniemi P, Turtola L: Long-term evaluation of estimates of need for third molar removal. J Oral Maxillofac Surg 58:288, 2000 14. 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 15. White RP Jr, Shugars DA, Shafer DM, et al: Recovery after third molar surgery: Clinical and health-related quality of life outcomes. J Oral Maxillofac Surg 61:535, 2003 16. Blakey GH, Parker DW, Hull DJ, et al: Impact of removal of asymptomatic third molars on periodontal pathology. J Oral Maxillofac Surg 67:245, 2009 17. Karimbux NY, Saraiya VM, Elangovan S, et al: Interleukin-1 gene polymorphisms and chronic periodontitis in adult whites: A systematic review and meta-analysis. J Periodontol 83:1407, 2012 18. Visser M, Bouter LM, McQuillan GM, et al: Elevated C-reactive protein levels in overweight and obese adults. JAMA 282:2131, 1999 19. Arnson Y, Shoenfeld Y, Amital H: Effects of tobacco smoke on immunity, inflammation and autoimmunity. J Autoimmun 34: J258, 2010
Effect of Quality of Life Measures on the Decision to Remove Third Molars in Subjects With Mild Pericoronitis Symptoms Dana T. Tang, DDS,* Ceib Phillips, PhD, MPH,y William R. Proffit, DDS, PhD,z Lorne D. Koroluk, DMD, MSD, MS,x and Raymond P. White, Jr, DDS, PhDk Purpose:
To assess how quality of life (QoL) measures affect the decision for third molar (3M) removal in patients with mild symptoms of pericoronitis.
Patients and Methods:
Healthy subjects, aged 18 to 35 years, with mild symptoms of pericoronitis were enrolled in an institutional review board–approved study. The demographic, clinical, and QoL data were collected at enrollment. The subjects voluntarily scheduled surgery for 3M removal. The principal outcome variable was their decision to undergo or not undergo surgery within 6 months of enrollment. The possible predictor variables in a multivariate logistic regression analysis were the demographic characteristics, dental insurance, and QoL measures.
The mean age of the 113 subjects was 23.2 3.8 years. Of the 113 subjects, 79 elected to undergo 3M removal within 6 months of enrollment (removed group) and 34 elected to retain their 3M at 6 months after enrollment (retained group). A significantly greater proportion of the removed group were white (58% vs 35%; P = .03) and reported having at least ‘‘a little trouble’’ with opening their mouths (38% vs 18%; P = .04) and taking part in social life (27% vs 6%; P = .01). The multivariate logistic regression model suggested the odds of electing 3M removal within 6 months of enrollment were greater for those who were white (odds ratio [OR] 2.69, 95% confidence interval [CI] 1.14 to 6.32) and those who had at least ‘‘a little trouble’’ with interactions in their social life (OR 3.22, 95% CI 1.08 to 9.58). Results:
Conclusions: In subjects with mild pericoronitis symptoms, experiencing problems with oral function and lifestyle, factors not often considered by clinicians, were significantly associated with subjects’ decision for early 3M removal. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-9, 2014
Pericoronitis is a chronic periodontal inflammatory condition associated with a partially or fully erupted tooth, most often a mandibular third molar (3M).1,2 This symptomatic condition will be commonly diagnosed in individuals aged 16 to 30 years and has a wide range of symptoms, including pain and swelling. The more severe clinical signs include purulence, trismus,
dysphagia, enlarged lymph nodes, and fever.1 Although an acute pericoronitis episode could last for only a few days, recurrences will typically follow, with a remission period of 7 to 15 months.1 Vent€a et al3 evaluated the history of patients with symptomatic 3Ms and found that 51% of reported patients had had 1 previous episode with the same tooth. The prevalence of pericoronitis
Received from University of North Carolina School of Dentistry,
Surgeons, and the Department of Oral and Maxillofacial Surgery,
Chapel Hill, NC.
University of North Carolina School of Dentistry.
*Senior Resident, Department of Orthodontics.
Address correspondence and reprint requests to Dr White:
yProfessor, Department of Orthodontics. zKenan Distinguished Professor, Department of Orthodontics.
Department of Oral and Maxillofacial Surgery, University of North Carolina School of Dentistry, Chapel Hill, NC 27599-7450; e-mail:
xAssociate Professor, Departments of Orthodontics and Pediatric
[email protected]
Dentistry.
Received December 13 2013
kDalton L. McMichael Distinguished Professor, Department of
Accepted March 24 2014 Ó 2014 American Association of Oral and Maxillofacial Surgeons
Oral and Maxillofacial Surgery. The present study was supported by the Oral and Maxillofacial
0278-2391/14/00335-8$36.00/0
Surgery Foundation, American Association of Oral and Maxillofacial
http://dx.doi.org/10.1016/j.joms.2014.03.022
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PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
has not been studied for the US population. Berge4 has reported the only population data for pericoronitis, with an approximately 9% prevalence, from a Norwegian population using reports from general dentists. Estimates from the available data have varied, ranging from 2 to 9%.4-6 Currently, the most effective treatment of pericoronitis is removal of the symptomatic tooth.7 The most prevalent 3M symptom is pain, usually associated with pericoronitis. Berge and Boe8 found, in a random sample of 176 general dentists, that pericoronitis contributed to 43% of 3M problems. Furthermore, pericoronitis has been the most commonly reported reason for 3M removal in young adults and older age groups.9 For example, in a cohort of patients 35 years or older, 41% reported pericoronitis as the reason for electing to have their 3Ms removed, followed by periodontal problems at 25%.9 In addition to symptoms of pain, pericoronitis also has an effect on one’s quality of life (QoL), including lifestyle and oral function.2 McNutt et al2 assessed the QoL of 57 subjects with mild symptoms of pericoronitis and found that 68% reported the worst pain they had experienced in the week before enrollment to be at least moderate in severity. Almost one quarter of the subjects reported oral function problems and had ‘‘quite a bit/lots’’ of difficulty with eating.2 Also, 19% had ‘‘quite a bit/lots’’ of difficulty with chewing.2 Removal of 3Ms will improve the QoL measures in patients with pericoronitis symptoms.10,11 McGrath et al10 assessed the QoL measures in 69 subjects with pericoronitis. At 6 months after having 1 mandibular 3M removed, the QoL had improved as measured using the 14-item Oral Health Impact questionnaire.10 Similarly, Bradshaw et al11 evaluated 60 subjects who had presented with mild symptoms of pericoronitis and elected to have all 3Ms removed. At a median of 7.7 months after surgery, significant improvements in the QoL measures were reported. For example, at enrollment, 15% of the subjects had reported their pain intensity in the week before enrollment as ‘ nothing,’ ‘ faint,’’ or ‘ very weak.’’ This outcome had improved to 97% at follow-up. Regarding oral function, 42% had reported having no difficulty with eating in the week before enrollment, and this had increased to 95% at follow-up.11 Although studies have clearly shown that pericoronitis negatively affects the QoL and that removal of the affected teeth can improve QoL, not everyone with these 3M problems will elect to have their 3Ms removed.12,13 In a longitudinal study by Vent€a et al,13 one third of the subjects had 3M symptoms, and most of the subjects with symptoms, 87%, but not all, underwent 3M removal.13 The question of which factors, in addition to the symptoms of pain, influence the decision to have 3Ms removed in subjects with pericoronitis remains.
The present study focused on the demographic characteristics, availability of dental insurance, and QoL measures as possible explanatory variables for a patient with mild pericoronitis symptoms to decide to remove or retain 3Ms within 6 months after enrollment.
Patients and Methods The subjects were enrolled in a study designed to better understand the clinical signs and symptoms of mild pericoronitis affecting mandibular 3Ms as they relate to oral and systemic inflammation. The subjects were recruited at a single academic clinical center, the University of North Carolina, for an institutional review board–approved, prospective, exploratory clinical study. The present study was registered with ClinicalTrials.gov (identifier NCT 01882270). All data from those enrolled from 2006 to 2012 with information about whether their 3Ms had been removed or retained at 6 months after enrollment were included in the analyses. Those who had undergone 3M removal were seen for follow-up at least 3 months after surgery.11 All those who had not undergone 3M removal were followed up for at least 1 year after enrollment. The inclusion criteria for the study specified that the subjects be aged 18 to 35 years, have a health risk assessment level of I or II according to the American Society of Anesthesiologists’ classification, and have mild signs or symptoms of pericoronitis, including spontaneous pain, purulence or drainage, and/or localized swelling, that affected at least 1 mandibular 3M. Those with severe signs or symptoms of pericoronitis, such as limited mouth opening, dysphagia, a temperature greater than 101 F, facial swelling or cellulitis, or severe uncontrolled discomfort were excluded. Additionally, those with a medical condition contraindicating periodontal probing, an acute illness, a body mass index (BMI) greater than 29 kg/m2, a history of antibiotic treatment within the previous 2 months, or generalized periodontal disease (Class IV according to the American Academy of Periodontology index) and those who used tobacco were excluded. Once consent to participate in the present study had been obtained, the demographic, clinical, and QoL data were collected from each subject. To assess the effect of mild pericoronitis on QoL in the previous week, at enrollment, the subjects were asked to complete the Health-Related QoL instrument, which includes 2 items in the pain domain and 4 each in the domains of lifestyle and oral function. The instrument was developed by Shugars et al14 specifically for 3M problems. The subjects were asked to report how their oral function and lifestyle had been affected in the week before enrollment using a 5-point Likert-type scale, ranging from ‘‘no trouble’’ (score 1) to ‘‘lots of trouble’’ (score 5). Because pain is the predominantly
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TANG ET AL
reported symptom of pericoronitis, the subjects were asked to assess their pain in the week before enrollment using a 7-point Likert-type scale. The 7-point scale for pain extended from ‘‘no pain’’ (score 1) to ‘‘the worst pain imaginable’’ (score 7). The items were categorized according to content into specific domains: oral function, lifestyle, and pain. The pain items were stratified as the worst and average pain. The thresholds of pain severity were reported as ‘‘no pain’’ (score 1), ‘‘little to moderate pain’’ (score 2 to 4), and ‘‘severe pain’’ (score 5 to 7). Oral function included the ability to eat, chew, talk, and open one’s mouth. Lifestyle included the ability to sleep, perform a daily routine, take part in social life, and participate in sports or hobbies. For the analyses, the thresholds of oral function and lifestyle effect were ‘‘no trouble’’ (score 1), ‘‘a little trouble’’ (score 2), and ‘‘more than a little trouble’’ (score 3 to 5), with the latter including the responses ‘‘some,’’ ‘‘quite a bit,’’ and ‘‘lots of trouble.’’ Gross debris was removed from the symptomatic 3Ms at enrollment, and analgesic medications were prescribed as needed for pain. The subjects were given the recommendation that their 3Ms should be removed as the most predictable treatment of the condition; however, no timetable for surgery was prescribed. The subjects voluntarily scheduled the surgery in consultation with their dentist. In accordance with the report from Bradshaw et al11 that had assessed QoL outcomes after surgery in subjects with mild pericoronitis, our subjects were divided into 2 groups: those who undergone surgery within 6 months of enrollment (removed group) and those who had not (retained group). The principal outcome variable for the analyses in the present study was the decision to undergo or not undergo surgery within 6 months of enrollment. The principal predictors or explanatory variables were the subjects’ reported QoL in the domains of oral function, lifestyle, and pain at enrollment. Other possible contributing variables were the demographic data (age, gender, ethnicity, and highest educational level) and the availability of dental insurance that would at least partially contribute to covering the surgical charges. The data entry and data management protocols were used as described previously by White et al.15 For the subjects in the removed and retained groups, the demographic characteristics and availability of insurance were compared using c2 analyses. The QoL measures were compared using Cochran-Mantel-Haenszel row mean score statistics. A logistic regression analysis using a 2-step forward selection approach was used to identify the QoL variables that contributed to the subject’s decision. The first model included only the demographic and availability of dental insurance variables. Statistically significant variables from the first model
were forced into the second forward selection model that included the QoL measures. The analyses were performed using Statistical Analysis Systems, version 9.2 (SAS Institute, Cary, NC). Significance was set at P < .05 for all analyses.
Results A total of 113 subjects with mild symptoms of pericoronitis were enrolled during a 6-year period from 2006 to 2012. Most subjects eventually elected 3M removal; only a few subjects retained their 3Ms for the entire study period, which amounted to at least 1 year (Fig 1). The mean age of the subjects at enrollment was 23.2 3.8 years. More subjects were female and white (56% and 51%, respectively; Table 1). Also, most subjects were well educated, with 92% reported having at least some college education. Less than one half of all subjects (41%) had dental insurance. The subjects in the removed category were more likely to be 23 years old or younger, but this pattern was not statistically significant (P = .11). The mean age of the 79 subjects at enrollment in the removed group was 22.8 3.5 years, and the mean age of the 34 subjects at enrollment in the retained group was 23.9 4.2 years. Differences in ethnicity existed between the 2 groups, with significantly more white subjects undergoing surgery within 6 months of enrollment compared with those delaying surgery later than 6 months or retaining their 3Ms (58% and 35%, respectively; P = .03). Additionally, more African-Americans were in the retained group (35%) than in the removed group (18%). Although only 41% of all subjects had dental insurance, more subjects in the removed group reported having dental insurance (47%) compared with the retained group (29%; P = .09; Table 1). A total of 79 subjects elected 3M removal within 6 months of enrollment, with a mean interval of 2.5 1.6 months after enrollment (Fig 1). Thirty-four subjects retained their 3Ms at 6 months after enrollment. Of these 34 subjects, 14 eventually underwent 3M removal; 9 had their 3Ms removed more than 1 year after enrollment. One half of the 34 subjects who retained their 3Ms at 6 months after enrollment (15% of the 113 subjects enrolled), still had their 3Ms at the last follow-up visit, at least 1 year after enrollment. The QoL measures in the oral function domain tended to be greater in the week before enrollment for the removed group than for the retained group. Significantly more subjects in the removed group (38%) had had at least ‘‘a little trouble’’ with mouth opening than in the retained group (18%; P = .04; Fig 2, Table 2). Although not statistically significant, a greater proportion of subjects in the removed group also reported higher scores or ‘‘more than a little
4
PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
FIGURE 1. Flow diagram of study participants enrolled with mild symptoms of pericoronitis. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
trouble,’’ for other oral function items than did the retained group (Fig 2, Table 2). For example, 38% of subjects in the removed group reported ‘‘more than a little trouble’’ with chewing compared with 33% in the retained group.
In the lifestyle domain, significantly more subjects in the removed group (27%) had at least ‘‘a little trouble’’ taking part in social life compared with the subjects in the retained group (6%; P = .01, Fig 3, Table 2). The difficulty with mouth opening and the
Table 1. DEMOGRAPHIC CHARACTERISTICS OF ALL SUBJECTS AT ENROLLMENT (N = 113)
Characteristic Age (yr) #23 >23 Gender Female Male Ethnicity White Nonwhite African-American Asian Hispanic Other Dental insurancek No Yes
Total (N = 113)
Third Molars Removed* (n = 79)
Third Molars Retainedy (n = 34)
66 (58.4) 47 (41.6)
50 (63.2) 29 (36.7)
16 (47.1) 18 (52.9)
63 (55.8) 50 (44.3)
43 (54.4) 36 (45.6)
20 (58.8) 14 (41.2)
58 (51.3) 55 (48.7) 26 (23.0) 14 (12.4) 6 (5.3) 9 (8.0)
46 (58.2) 33 (41.8) 14 (17.7) 9 (11.4) 6 (7.6) 4 (5.1)
12 (35.3) 22 (64.7) 12 (35.3) 5 (14.7) 0 (0.0) 5 (14.7)
65 (58.6) 46 (41.4)
41 (53.3) 36 (46.8)
24 (70.6) 10 (29.4)
P Valuez .11
.67 .03x
.09
Data presented as n (%); percentage totals might not equal 100% because percentages were rounded to the nearest tenth decimal place. * Removed within 6 months of enrollment. y Retained at 6 months after enrollment. z P values computed using c2 test. x P < .05. k Data missing for $1 subjects. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
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FIGURE 2. Comparison of the distribution of subjects reporting difficulty with oral function in the week before enrollment for the removed (n = 79) and retained (n = 34) groups. The removed group consisted of subjects who had elected third molar removal within 6 months of enrollment. The retained group consisted of subjects who had retained their third molars at 6 months after enrollment. The percentage totals might not equal 100% because the percentages were rounded to the nearest whole number. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
effect on social interactions were significantly correlated (rs = 0.49; P < .0001). Compared with the oral function items, the proportion of subjects in the removed and retained groups who reported at least ‘‘a little trouble’’ in the lifestyle items tended to be smaller. However, more subjects in the removed group than in the retained group reported at least ‘‘a little trouble’’ in all the lifestyle measures. The mean scores for the worst and average pain in the week before enrollment were at the lower end of the 7-point Likert-type scale, compatible with the enrollment criteria for the study. The mean worst and average pain levels were not significantly different between the removed and retained groups (P = .30 and P = .59, respectively; data not shown). More subjects had reported their worst pain levels in the week before enrollment as severe in the removed group (27%) than in the retained group (15%; P = .23; Fig 4, Table 2). Few subjects in both groups reported their average pain as severe. The multivariate logistic regression models suggested 2 factors that increased the odds of early surgery: ethnicity and an item in the lifestyle domain, the amount of difficulty the subjects had with interactions in their social life. Both were associated with the subjects’ decision to have the 3Ms removed within 6 months of enrollment. Whites were more
likely to have their 3Ms removed within 6 months of enrollment than were nonwhites (odds ratio [OR] 2.69, 95% confidence Interval [CI] 1.14 to 6.32). Having at least ‘‘a little trouble’’ with participating in social life at enrollment compared with ‘‘no trouble’’ increased the chances of a decision for early surgery (OR 3.22, 95% CI 1.08 to 9.58). Those subjects with ‘‘more than a little trouble’’ participating in social life compared with ‘‘no trouble’’ were more likely (OR 10.33, 95% CI 1.16 to 91.86) to have had their 3Ms removed within 6 months.
Discussion The data we have reported suggest that for subjects with symptomatic 3Ms and pain scores on the lower end of a 7-point Likert-type scale, factors other than pain will also influence an individual’s decision for early surgery. On average, our study subjects who elected surgery did so within 3 months after enrollment. The QoL measures for the oral function and lifestyle domains were significantly associated with the decision for early 3M removal. Although 15% of the 113 enrolled subjects retained their 3Ms at the longest follow-up point, the odds of electing early surgery were 3 times greater for those whose lifestyle was
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PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
Table 2. SUBJECTS’ QUALITY OF LIFE MEASURES IN WEEK BEFORE ENROLLMENT
Quality of Life Measure Trouble with eating No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with chewingx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with talkingx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with mouth opening No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with sleepingx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble performing daily routine No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with taking part in social life No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Trouble with participating in sportsx No trouble (score 1) A little trouble (score 2) More than a little trouble (score 3-5) Worst pain No pain (score 1) Little to moderate pain (score 2-4) Severe pain (score 5-7) Average pain No pain (score 1) Little to moderate pain (score 2-4) Severe pain (score 5-7)
Total (n=113)
Third Molars Removed (n=79)*
Third Molars Retained (n=34)y
45 (39.8) 24 (21.2) 44 (38.9)
32 (40.5) 16 (20.3) 31 (39.2)
13 (38.2) 8 (23.5) 13 (38.2)
41 (36.6) 30 (26.8) 41 (36.6)
29 (36.7) 20 (25.3) 30 (38.0)
12 (36.4) 10 (30.3) 11 (33.3)
94 (83.9) 15 (13.4) 3 (2.7)
63 (79.8) 14 (17.7) 2 (2.5)
31 (93.9) 1 (3.0) 1 (3.0)
77 (68.1) 24 (21.2) 12 (10.6)
49 (62.0) 20 (25.3) 10 (12.7)
28 (82.4) 4 (11.8) 2 (5.9)
79 (70.5) 19 (17.0) 14 (12.5)
55 (70.5) 12 (15.4) 11 (14.1)
24 (70.6) 7 (20.6) 3 (8.8)
77 (68.1) 24 (21.2) 12 (10.6)
51 (64.6) 17 (21.5) 11 (13.9)
26 (76.5) 7 (20.6) 1 (2.9)
90 (79.7) 14 (12.4) 9 (8.0)
58 (73.4) 13 (16.5) 8 (10.1)
32 (94.1) 1 (2.9) 1 (2.9)
97 (86.6) 9 (8.0) 6 (5.4)
67 (85.9) 7 (9.0) 4 (5.1)
30 (88.2) 2 (5.9) 2 (5.9)
12 (10.6) 75 (66.4) 26 (23.0)
8 (10.1) 50 (63.3) 21 (26.6)
4 (11.8) 25 (73.5) 5 (14.7)
27 (23.9) 80 (70.8) 6 (5.3)
18 (22.8) 56 (70.9) 5 (6.3)
9 (26.5) 24 (70.6) 1 (2.9)
P Valuez .94
.81
.07
.04k
.87
.15
.01k
.76
.23
.52
Data presented as n (%); percentage totals might not total 100% because percentages were rounded to the nearest tenth decimal place (n=113). * Within 6 months of enrollment. y Retained at 6 months after enrollment. z P values computed using Cochran Mantel-Haenszel row mean score statistics. x Data missing for one subject. k P < .05. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
compromised with at least ‘‘a little trouble’’ compared with those who reported no such problems. QoL issues were not the only factors associated with the decision for early surgery. The odds were more than 2.5 times more likely that whites compared
with the other enrolled ethnic groups would elect early surgery. We have no data to explain these differences. Although fewer than one half of the subjects had dental insurance that might have reduced some of the surgical charges, those with dental
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TANG ET AL
FIGURE 3. Comparison of the distribution of subjects reporting difficulty with lifestyle in the week before enrollment for the removed (n = 79) and retained (n = 34) groups. The removed group consisted of subjects who had elected third molar removal within 6 months of enrollment. The retained group consisted of subjects who had retained their third molars at 6 months after enrollment. The percentage totals might not equal 100% because the percentages were rounded to the nearest whole number. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
insurance tended to elect to have their 3Ms removed early. This suggests that financial assistance with the charges for surgery could play a role in the decision for 3M removal. Although we have reported that additional factors might be influential, most clinicians will assume correctly that the pain resulting from localized inflammation is a major factor involved in 3M removal decisions. All subjects who had their 3Ms removed reported pain as the primary, but not the sole, reason for electing surgery. Clinicians readily associate pericoronitis with recurring painful episodes. Vent€a et al3 evaluated the history of patients who presented with symptomatic 3Ms and found that one half had had 1 previous episode with the same tooth, more than one third had had 2 or more episodes with the same tooth, and about two thirds had had symptoms with another 3M. Furthermore, White et al15 evaluated the recovery after 3M surgery and found that previous symptoms of pain or swelling played a role in the decision for surgery in 37% of the subjects. Also, 78% reported they had elected surgery to avoid future problems.15 Our definition of ‘‘early’’ versus ‘‘late’’ surgery was based on the report by Bradshaw et al,11 in which subjects averaged less than 3 months from enrollment to surgery. A doubling of this period as the threshold for early surgery was somewhat arbitrary; however,
gave individuals sufficient time to elect surgery, taking into account daily demands, such as vacations, holidays, and examinations. For the removed group, the average interval to surgery was 2.5 months. It is important to add that 82% of the subjects with mild symptoms of pericoronitis who enrolled in our study eventually underwent 3M removal; only 8% underwent surgery more than 1 year after enrollment. Most subjects in our study elected surgery relatively quickly after enrollment. Blakey et al16 reported that for subjects with asymptomatic 3Ms, the median interval from enrollment to surgery was 2.4 years. This was 12 times longer than the 2.5 -month period for the ‘‘early’’ group of subjects in our study. Our study had limitations. Our sample consisted of young, well-educated individuals, typical of patients frequenting an academic center in a university community and not representative of the US population who might have this condition. Our study excluded subjects with severe symptoms of pericoronitis, because these individuals could not ethically be asked to retain their 3Ms in a longitudinal study without active treatment. The inflammatory response to pathogens might differ for those with more severe symptoms of pericoronitis.17 Also, more severe pericoronitis symptoms could have a greater effect on QoL and the resulting decision and timing for 3M removal in affected individuals.17 Our study excluded
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PERICORONITIS, QOL MEASURES, AND THIRD MOLAR REMOVAL
FIGURE 4. Comparison of the distribution of subjects reporting pain in the week before enrollment for the removed (n = 79) and retained (n = 34) groups. The removed group consisted of subjects who had elected third molar removal within 6 months of enrollment. The retained group consisted of subjects who had retained their third molars at 6 months after enrollment. The percentage totals might not equal 100% because the percentages were rounded to the nearest whole number. Tang et al. Pericoronitis, QOL Measures, and Third Molar Removal. J Oral Maxillofac Surg 2014.
subjects with medical conditions contraindicating periodontal probing, antibiotic use, or generalized periodontal disease. In addition, those with a BMI greater than 29 kg/m2 or who used tobacco were excluded because of the possible circulating inflammatory mediators from these conditions affecting the oral inflammatory response.18,19 Although the number of subjects in our study was adequate to demonstrate differences based on the decision for early or late surgery, the small numbers of subjects with lifestyle or oral function Likert scores of 3 to 5 of a total of 5 limited the conclusions from the statistical analyses and the generalizability to other populations. Future studies, to provide data more representative of the entire US population, should include a larger number of subjects and those who might not be as healthy. However, interested clinical investigators should be cautioned that, overall, fewer than 10% of young adults might have pericoronitis symptoms, making enrollment of an adequate numbers of subjects protracted.4-6 This outcome was reflected in the 6-year period required to enroll our subjects for the present study. How might clinicians use this data? Clinicians should not assume that only the pain symptoms will be important to a patient’s decision for surgical removal of symptomatic 3Ms. Additional information
on how QoL might have been affected should be documented. Making patients aware of the recurring nature of the pain and the other QoL issues should be a part of the consultation process for a patient and the information shared with referring clinicians. Furthermore, considerations of how pericoronitis affects QoL should lead to alterations in the practice guidelines for the management of 3Ms. Acknowledgments The authors would like to thank the volunteers who participated in our study, Ms Debora Price for her assistance in managing the data in this project, and Ms Tiffany Hambright for her assistance as the clinical coordinator.
References 1. Kay LW: Investigations into the nature of pericoronitis. Br J Oral Surg 3:188, 1966 2. McNutt M, Partrick M, Shugars DA, et al: Impact of symptomatic pericoronitis on health-related quality of life. J Oral Maxillofac Surg 66:2482, 2008 3. Vent€a I, Turtola L, Murtomaa H, Ylipaavalniemi P: Third molars as an acute problem in Finnish university students. Oral Surg Oral Med Oral Pathol 76:135, 1993 4. Berge TI: Third molars in Norwegian general dental practice. Acta Odontol Scand 50:17, 1992 5. Leone SA, Edenfield MJ: Third molars and acute pericoronitis: A military problem. Mil Med 152:146, 1987
TANG ET AL 6. Rajasuo A, Murtomaa H, Meurman JH: Comparison of the clinical status of third molars in young men in 1949 and in 1990. Oral Surg Oral Med Oral Pathol 76:694, 1993 7. Blakey GH, White RP Jr, Offenbacher S, et al: Clinical/biological outcomes of treatment for pericoronitis. J Oral Maxillofac Surg 54:1150, 1996 8. Berge TI, Boe OE: Symptoms and lesions associated with retained or partially erupted third molars: Some variables of third-molar surgery in Norwegian general practice. Acta Odontol Scand 51:115, 1993 9. Bruce RA, Frederickson GC, Small GS: Age of patients and morbidity associated with mandibular third molar surgery. J Am Dent Assoc 101:240, 1980 10. McGrath C, Comfort MB, Lo EC, Luo Y: Can third molar surgery improve quality of life? A 6-month cohort study. J Oral Maxillofac Surg 61:759, 2003 11. Bradshaw S, Faulk J, Blakey GH, et al: Quality of life outcomes after third molar removal in subjects with minor symptoms of pericoronitis. J Oral Maxillofac Surg 70:2494, 2012 12. Kinard BE, Dodson TB: Most patients with asymptomatic, disease-free third molars elect extraction over retention as their preferred treatment. J Oral Maxillofac Surg 68:2935, 2010
9 13. Vent€a I, Ylipaavalniemi P, Turtola L: Long-term evaluation of estimates of need for third molar removal. J Oral Maxillofac Surg 58:288, 2000 14. 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 15. White RP Jr, Shugars DA, Shafer DM, et al: Recovery after third molar surgery: Clinical and health-related quality of life outcomes. J Oral Maxillofac Surg 61:535, 2003 16. Blakey GH, Parker DW, Hull DJ, et al: Impact of removal of asymptomatic third molars on periodontal pathology. J Oral Maxillofac Surg 67:245, 2009 17. Karimbux NY, Saraiya VM, Elangovan S, et al: Interleukin-1 gene polymorphisms and chronic periodontitis in adult whites: A systematic review and meta-analysis. J Periodontol 83:1407, 2012 18. Visser M, Bouter LM, McQuillan GM, et al: Elevated C-reactive protein levels in overweight and obese adults. JAMA 282:2131, 1999 19. Arnson Y, Shoenfeld Y, Amital H: Effects of tobacco smoke on immunity, inflammation and autoimmunity. J Autoimmun 34: J258, 2010
