Trond Inge Berge

Predictor evaluation of postoperative morbidity after surgical removal of mandibular third molars

The effect of several pre- and per-operative variables on indicators of postoperative morbidity was assessed in 204 patients after unilateral mandibular third-molar surgery. The variables included gender, age, use of tobacco and alcohol, state of eruption, depth and angulation of the tooth, duration of the operation, pericoronitis, and time of day of surgery. Visual analogue scales were used for patient assessment of pain and swelling and for clinical assessment of swelling. Maximum pain was indicated 6 h postoperatively and maximum swelling the first postoperative evening. The results showed a mean reduction of mouth opening capacity (trismus) of 31% the 1st postoperative day. Mean analgesic consumption was 3.7 tablets, mean number of days of inability to work 1.1, and the rate of postoperative alveolitis 1.9%. The variation of the morbidity indicators was considerable. Multiple classification analyses showed that the predictors explained from 17% (clinically assessed swelling) to 8% (pain 6 h postoperatively) of the variance of these indicators. It is concluded that these commonly used predictors only to a minor extent can explain the wide variation in postoperative morbidity after mandibular third-molar surgery.

Acceptance and side effects of nitrous oxide oxygen sedation for oral surgical procedures

Two hundred and forty-one treatment sessions with nitrous oxide oxygen sedation were performed in 194 patients undergoing ambulatory oral surgery procedures. Removal of mesiodentes and tooth transplants were the most frequent procedures in age groups under 13 years, while removal of impacted teeth was predominant in older age groups. Local anesthesia was used in addition to inhalation sedation in 238 sessions. Median gas volume rate was 10 l/min, median concentration 50% and median duration of procedures 31 min. In 10 sessions (4.1%) sedation was not accepted, while in 25 (10.4%) sessions the procedure could be completed with some difficulty. No potentially dangerous complications were noted. Side effects occurred in 18 sessions in 16 patients. All side effects were minor and easily handled. Logistic regression analysis revealed that failure, defined as poor acceptance and/or presence of side effects, was associated with ASA class 2 and general apprehension, especially based on previous negative experience with medical or dental treatment. Nitrous oxide oxygen sedation is a reliable, efficient and safe adjunct to local anesthesia in both healthy children and adults undergoing ambulatory oral surgery procedures.

Visual analogue scale assessment of postoperative swelling: A study of clinical inflammatory variables subsequent to third-molar surgery

Subsequent to removal of impacted lower third molars the interrelationship of four postoperative variables (swelling, pain, trismus, and dysphagia) was assessed. Patient assessment of postoperative swelling using a visual analogue scale (VAS) was easily accepted by a group (n = 40) of patients aged 17 to 46 years. A significantly positive correlation (r = 0.66, p less than 0.01) existed between metric extraoral swelling and VAS-assessed swelling; however, the latter may represent a more sensitive method when swelling is discrete. Both extraorally and VAS-assessed swelling showed no correlation with dysphagia and VAS-assessed pain. Trismus correlated moderately positively with pain and extraoral swelling (r = 0.38, p less than 0.05) and dysphagia (p less than 0.01). In the present study dysphagia showed no correlation with pain. This study shows that registration of postoperative swelling by means of a VAS may be a sensitive and accurate method with obvious practical advantages.

Per- and post-operative variables of mandibular third-molar surgery by four general practitioners and one oral surgeon

Per- and post-operative indicators in 25 patients who had lower third-molar surgery performed by 4 general practitioners (GP) in their own practices were compared with those of a control group of 25 patients operated on by an oral surgeon. The preoperative variables age; sex; general health; use of medications, alcohol, and tobacco; and depth, position, and presence of infection of the third molar were considered in individual matching of the patients. The operations performed by the GPs lasted 17.9 min (p = 0.0001) longer than those of the oral surgeon. Increased rates of postoperative alveolitis (p = 0.03) and secondary healing (p = 0.0005) were found in the GP patient group, as was a tendency for increased postoperative pain and consumption of strong analgesics. The number of days unable to work was 1.9 in the GP group, compared with 0.6 in the surgeon group (p = 0.0012). No differences in swelling and trismus were found.

The use of a visual analogue scale in observer assessment of postoperative swelling subsequent to third-molar surgery

Postoperative swelling after mandibular third-molar surgery was evaluated in 40 patients. Three-dimensional metric measurement of swelling was compared with observer assessment of swelling from clinical examination, from pairs of en-face photographs, and from patient self-assessment, all using a 50-mm visual analogue scale (VAS) for registration. The photographs were evaluated by two groups of observers: general practitioners (n = 5) and oral surgeons (n = 5). The following conclusions were drawn: observer assessment of swelling from clinical examination and from judgement of photographs underestimates large swelling and slightly overestimates small or no swelling compared with objectively measured swelling. General practitioners and oral surgeons assess swelling from photographs almost identically, with a slight tendency for more underestimation of large swelling by the younger oral surgeons. A 50-mm VAS seems sufficiently reliable for assessment of swelling.

Inability to work after surgical removal of mandibular third molars

Inability to work after mandibular third-molar surgery was studied in 201 patients operated on in a specialist clinic. Mean indicated inability to work was 1.07 days; 95% confidence interval, 0.91-1.23 days; range, 0-6 days. Eighty-six (43%) patients did not indicate any reduction in working ability. Duration of operation more than 14 min, heavy smoking (> 19 cigarettes/day), and female sex were associated with prolonged inability to work. Self-administered analgesic consumption and pain scores over the first postoperative week showed positive correlations with inability to work: r = 0.44 and 0.41, respectively. Other indicators of the normal postoperative reaction were to a lesser extent associated with reduced ability to work. Total sick-leave cost in Norway associated with surgical third-molar removals, adjusted for age-related income, employment rate, treatment rate, and provider of treatment, was 46.4 million NOK per year.

Incidence of chronic neuropathic pain subsequent to surgical removal of impacted third molars

To determine the incidence of atypical odontalgia/chronic neuropathic pain subsequent to surgical removal of impacted third molars, a telephone survey and a clinical investigation were carried out. Patients operated on for impacted mandibular third molars during 1994-96 in the Oral Surgery Clinic, School of Dentistry, University of Bergen, Bergen, Norway, were contacted by telephone. Answers were obtained from 1035 (71%) out of a total of 1458 operated patients. Median observation time was 5 years 9 months, ranging from 4 years 5 months to 6 years 9 months. All except 23 (2.2%) patients stated that they had no long-term symptoms or problems from the surgical site, jaw, or face after the third molar removal. These 23 patients were all examined clinically and radiologically, and symptoms and findings were evaluated. Seventeen patients had TMJ dysfunction: primarily pain of muscular and joint origin. Three patients had a periodontal problem associated with the adjacent second molar, with deep bony pockets and recurrent periodontal infection while two had chronic pulpitis of a second molar. One patient reported a temporary maxillary pain after removal of an ipsilateral mandibular third molar. None of the patients met the criteria for a diagnosis of atypical odontalgia/neuropathic pain. A 95% confidence interval of 0-0.38% of incidence rate of postoperative neuropathic pain was calculated. It is concluded that atypical odontalgia/ chronic neuropathic pain subsequent to surgical third molar removal is rare.

Pattern of self-administered paracetamol and codeine analgesic consumption after mandibular third-molar surgery

Pattern of analgesic consumption after unilateral mandibular third-molar surgery was investigated in an open study in 201 patients. All patients were supplied with six analgesic tablets containing 500 mg paracetamol and 30 mg codeine. Instructions for use were given. A mean consumption of 4.9 tablets over the 1st week and 3.6 tablets the day of operation was found. Eight (4%) patients indicated inadequate or no effect of the medication. The remaining patients were able to control pain, to a level of one-third of maximum pain, by using from one to five tablets. One hundred and thirty-two (68%) patients followed instructions with regard to start of medication. No difference in mean tablet consumption was found between compliant patients and those who delayed the intake of the first analgesic dose by more than 1 h. Predictor analysis showed the most powerful predictors to be preoperative depth of the third molar and moderate or heavy smoking. Thirteen per cent explanatory power of all predictors together was found.

Oral surgery in Norwegian general dental practice—a survey Extent, scope, referrals, emergencies, and medically compromised patients

A questionnaire containing 37 questions concerning oral surgery and oral medicine was mailed to a systematic random sample of 500 Norwegian general dental practitioners in October 1989. A 60% return rate was obtained. From the 20 questions included in this paper the following conclusions were drawn: Norwegian general practitioners perform a substantial number and diversity of procedures in the field of oral surgery and oral medicine. The predictor variables sex, age, geographic location, and type of practice (private/public) showed by multiple classification analysis only limited correlation with the amount and diversity of procedures. On average, 12.3 patients were referred per practitioner per year to specialists in oral surgery. The indicated need for orthognathic consultations was 0.75 patient per year per practitioner. Serious emergencies demanding referral seldom occurred. Each month 6.6 medically compromised patients were seen in general practice, among which cardiovascular disorders dominated.

General practitioners’ and dental students’ decisions on third-molar diagnoses, treatment, and referrals

A questionnaire on third-molar problems was mailed to a systematic random sample of 200 Norwegian general dental practitioners in November 1991. The return rate was 88%. Similar questions were given to 59 5th-year dental students, with a return rate of 83%. Ten third-molar cases were presented by means of copies of radiographs and written information. The following conclusions were drawn: Apart from a terminology problem consisting of lack of discrimination between the terms retention and impaction, overall good diagnostic abilities were shown by both practitioners and students. Receiver operating characteristic analysis of treatment decisions indicated that students were more radical than practitioners. The students had an increased referral rate for third-molar surgery, whereas the practitioners indicated a more selective practice of referring advanced cases.