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© Masoud Kiani, Pankevych A. I. UDC 616.314.9:615.327 Masoud Kiani, Pankevych A. I.
EXTRACTION OF THIRD MOLAR AND IT'S RELATIONSHIP
WITH GRADING OF PAIN
Ukrainian Medical Stomatological Academy (Poltava)
Introduction. Four types of teeth, being the eruption after another teeth are called wisdom teeth or third molar, start at the approximate age is 9 till 10 years old in the jawbone and crown completed in 14 years old and in the last years of adolescence begin to eruption inside the bone and after the age of 16 till 25 years old appear in the mouth. Due to lack of a natural form of wisdom teeth like many other teeth and perch at the end of the jaw and do not clean them when brushing, so vulnerable and usually sooner than other teeth are caries. Restoration and filling wisdom teeth are difficult; so, to extract the wisdom teeth [2,5,8].
Wisdom teeth surgery is one of the most common procedures performed in oral surgery. Nevertheless, this procedure requires accurate planning and surgical skills. With surgical procedures in general, complications can always arise. The reported frequencies of complications after removal third molar are reported between 2.7% and 29.9% [17].
Postpone the extraction of third molar into old age may cause the following complications [20]:
- Reduce recovery after tooth extractions;
- Dental caries on adjacent tooth;
- The possibility of welding jaw teeth;
- The roots were thicker, with increase age and may be more difficult tooth extractions.
Also, generally complications of removal wisdom teeth are: pain, swelling, trismus, malaise, hemorrhage, fractures of the mandible and the maxilla, damage to adjacent teeth, alveolar osteitis, periodontal damage, soft-tissue infection and temporary paresthesia (numbness of the lips, tongue and cheek) [21].
Although impacted third molar may remain symptom-free indefinitely, they may be responsible for significant pathology. Pain, pericoronitis, development of periodontal disease on the second molar, crown and/ or root resorption of the second molar, caries in third or second molars and TMJ-symptoms are associated with retained third molars (Figure 1) [7].
There are numerous recent studies, which identify risk factors for intraoperative and/or postoperative complications [4,5,20]. Common intra- and postoperative complications and side effects associated with removal third molar are summarized in the Table.
For the general dental practitioner, as well as the dental surgeon, it is important to be familiar with all the possible complications. This improves patient education and leads to early recognition and management. In this study, complications are considered rare or unusual if the incidence is commonly quoted below 1%. The aim
of this systematic research is to remind us of the unusual complications associated with third molar surgery [2].
Prophylactic removal of third molars should be based on an estimate of the balance between the risks and advantages of retained wisdom teeth because there is no reliable research to suggest that the removal of disease-free, impacted third molars is beneficial to patients and because unnecessary surgery exposes patients to risks [21]. Surgical removal of third molars is often accompanied by complications such as: pain, swelling, bleeding, trismus and general oral dysfunction during the healing phase; less commonly, nerve damage, damage to adjacent teeth, fracture of the mandible and oro-antral communication can occur [1,6].
There are various indications for extraction, such as: prevention of pericoronaritis, this being the most frequent indication; prevention of caries in the third molar or in the distal region of the second molar; prevention of second molar root reabsorption; prevention of odontogenic cyst and tumor formation; and prevention of mandibular fractures [9].
Pain after the extraction third molar is a routine sequela due to trauma induced inflammation. Thus, third molar surgery is one of the most often used intervention to study acute analgesia, [19] but very few have evaluated factors that may predict the post surgery pain intensity [12,13].
The aim of this prospective and exploratory study was to evaluate the postoperative pain intensity in a diverse sample of individuals who had a single third molar removed and check whether some predictive variables could have influence over patients postoperative pain experience. Better understanding these specification of pain may guide the dentists through perioperative decisions or may launch an alert of developing complications which could help the professional to better and faster handle it.
Materials and Methods. Surgical extraction of a single third molar was performed on 100 continuous patients, between age range 18 to 45 years (37 males and 63 females). 45 third molars were removed from the maxilla (16 males and 29 females) and 55 from the mandible (21 males and 34 females).
The study was carried out under controlled conditions and performed in two similar surgical rooms. All the procedures were performed by undergraduate students with little of experience and under direct supervision of two oral surgeons. All extractions were made at same period of the day, between 10:00 to 16:00, and from 5th September of 2015 to 28th January of 2016.
a
Upper
wisdom tooth Lower
wisdom tooth
b
Ophthalmic n. Maxillary n Trigeminal n,
Temporal branch of facial n.
Marginal mandibular branch of facia] n.
Cervical branch of facial n.'
Medial pterygoid m.
Figure 1. a) Upper and lower third molars. b) Nerves around the TMJ.
All procedures were performed under the meticulous hygiene conditions that included sterile surgical apron, mask, cap medical, gloves and sheets with dental hand pieces and surgical instruments sterilized in autoclave. Sterile saline solution was used for lavage of the alveolus socket and for bur refrigeration when os-tectomy or odontomy was necessary.
Before surgery, patients had to rinse for 70 second with 15 ml of 0.02% Chlorhexidine solution.
Due to ethical reasons, selective non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed to all patients (Tablet Meloxicam 15 mg, 3 times a day, for 2 days).
Tablet Diclofenac potassium 50 mg, 3 times a day, for 2 days were prescribed only to those patients whom the surgical trauma was considered extensive or to those whose pain was not controlled by the prescribed Meloxicam.
However, it was allowed to the patient to discontinue these drugs (Meloxicam or Diclofenac potassium) or even do not take it, if no symptoms were present but patients were advised to take the NSAIDs tablet as soon as their pain started.
Antibiotics Augmentin 625 (Amoxicillin 500 mg and Clavulanic acid 125 mg) were administrated in all patients 2 times a day during 5-7 days. The postoperative cares and recommendations were similar to all patients and were directed mainly to keep the blood clot in place, avoiding rigorous mouthwash, maintaining a sensible oral hygiene and keep at least 12 hours rest. The patients were evaluated clinically at the first, third and seventh day post-surgery or whenever necessary [16].
Data were collected by a dentist who was present in all procedures. Anamnestic data were collected by means of a questionnaire together with a panoramic radiograph and routine blood test. Data regarding the surgical procedure were collected instantly after the surgery.
Patients had to evaluate the pain intensity at the end of the first (day 1), second (day 2) and third (day 3) postoperative day by means of a visual analog scale (VAS) with the anchor points 0 (no pain) and 10 (ex-
treme pain). They had to grade the most severe pain felt during the day.
Differences in pain intensity at the three follow-up days were analyzed by means of the Spearman correlation test and Chi-square test (XX2) as appropriate. For this, last evaluation pain level and age were dichotomized.
VAS 0-2 is pain free or light pain; VAS 3-10 is severe to moderate pain. The age was dichotomized at 24 years (median). The statistical analysis was performed by means of the BioEstat(version 5.0). Differences were considered as statistically significant with p < 0.05.
Results. The reported pain levels for the first postoperative day were significantly higher compared with second and third days (Figure 2). At first day, moderate and severe pain were observed predominantly in patients who had surgery in the mandible (p < 0.001) and for patients younger than 24 years (p = 0.009), while more patients who weekly consumed Meloxicam showed pain classified as none or light (p = 0.017) (Table).
At second day, the profile of pain moderate/severe was more prevalent for patients who had surgery in the mandible (p < 0.001) with the report of difficult surgery (p = 0.042) and with odontotomy performed (p = 0.033) (Table).
At third day, severe/ moderate pain was associated with surgery in the mandible (p < 0.001) and with odontotomy (p = 0.021) and ostectomy (p = 0.028) performed, with report of long and difficult procedure (p = 0.023), surgeries which last more than sixty minutes (p < 0.026), and for those patients who developed postoperative complications (p < 0.001) (Table).
The surgery time was weekly and positively correlated (Spearman correlation test) with the pain intensity for the first (rs = 0.22), second (rs = 0.21) and third (rs = 0.27) days.
The anatomical teeth position in the mandible or maxilla and its respective mean pain scores for first to third days can be seen in Figures 2 and 3.
Discussion. This study showed the potential suitability of Meloxicam and Diclofenac potassium for the
Table.
Proportions and Pearson Chi-square test (p<0.05, two sided) for some variables of interest and respective association with grading of pain dichotomized as none/light (VAS 0-2) and moderate/severe (VAS 3-10) for days 1 to 3, after third molar extraction (n: 100)
Variables Pain level (day 1) c2 (p-value) Pain level (day 2) c2 (p-value) Pain le vel (day 3) c2 (p-value)
None/ light (0-2) Moderate/ severe (3-10) None/ light (0-2) Moderate/ severe (3-10) None/ light (0-2) Moderate/ severe (3-10)
Gender Male 25 12 NS 33 4 NS 32 5 NS
Female 38 25 46 17 48 15
Age (median) Up to 24 29 27 0.009 44 12 NS 47 9 NS
More than 24 34 10 35 9 33 11
Osteotomy Yes 30 23 NS 38 15 NS 38 15 0.028
No 33 14 41 6 42 5
Odontotomy Yes 15 10 NS 16 9 0.033 16 9 0.021
No 48 27 63 12 64 11
Report of difficult surgery Yes 21 17 NS 26 12 0.042 26 12 0.023
No 42 20 53 9 54 8
Surgical accident (root fracture, etc.) Yes 4 4 NS 6 2 NS 6 2 NS
No 59 33 73 19 74 18
Procedures time (median-in minute) Up to 60 37 20 NS 47 10 NS 50 7 0.026
More than 60 26 17 32 11 30 13
Surgical site Maxilla 36 9 0.001 43 2 < 0.001 43 2 < 0.001
Mandible 27 28 36 19 37 18
Post-operative infection or dry socket Yes 4 1 NS 4 1 NS 0 5 < 0.001
No 59 36 75 20 80 15
Antibiotic prescription Yes 23 9 NS 25 7 NS 22 10 NS
No 40 28 54 14 58 10
NS: Non-Significant
management of our patients who have undergone oral surgical procedures.
It was found to be superior in controlling post-operative pain and swelling with Diclofenac potassium in similar onset and prolonged duration of action when compared with Meloxicam.
In this study was to analyze how different individuals perceive the pain after a third molar extraction and to identify factors that may predict the post surgery pain intensity.
Besides the limitations of this exploratory study, we are able to raise some interesting questions and compare our results with the current literature. Interestingly, a regular Meloxicam consumption, especially when taken daily, reduced pain intensity during the first post-surgery day. This observation is likely explained by an anti-inflammatory and/or analgesic effect of Meloxicam [10,11].
The anti-inflammatory action was related with the decrease in inflammatory cytokine expression, cell influx and cellular metabolic activity and also with promotion of cell survival due to its prevention, interception and repair protection against peroxynitrite, which causes protein nitration, lipid peroxidation, DNA damage and cell death. Nitrosative stress is induced when-
ever the conditions are favorable for increased superoxide formation, like cellular damage due to trauma [7,8].
In figure 4, shows a large decrease in pain intensity after removal of a maxillary tooth from first day to third day, independently of the tooth position.
However, the postoperative pain course was more complex after the extraction of a mandibular tooth. Indeed, with a distoangular and a mesioangular tooth position pain increased from first day to second day and in the latter position also between second and third days (Figure 3).
This can be explained by the fact that this tooth position required a more complex surgery that therefore, caused a more severe trauma and subsequent increased inflammatory process. On comparing figures 3 and 4, it is visible that the highest mean pain scores for maxillary teeth were situated at the inferior baseline pain scores for mandibular teeth and, in fact, mandibular teeth were observed to be a more painful surgery for all three days recorded. The use of postoperative antibiotics for the removal of asymptomatic third molars is controversial [5,18,21].
We concluded to recommend routine oral antibiotic prophylaxis in third molar surgery. In the present study
observed that the use of antibiotics show a beneficial effect over pain's response, in accordance with the literature.
At second and third days, it becomes more apparent that higher pain levels are related with the increase of surgical trauma in mandibular surgery, with more difficult surgeries implying in ostectomy and odontotomy and for a low experienced student who conducted the surgery, that means increase in time spent for accomplish the procedure.
Regarding to the period of infection development, our study is in accordance with the results found by Alexander and Throndson (2000) [3] which, in a review manuscript, suggested that infection arise usually at the second or mainly at third day postoperative and are related with increase of pain complaint. Similarly, to what was found in the present study, Kim et al (2006) [14] showed that patients who had deeply impacted teeth which implies in more difficult procedure and larger operation time have significantly higher pain scores compared with short operation times. Baqain et al (2008) [6] observed that postoperative pain was associated with tooth angulations, bone removal, tooth sectioning, lingual flap retraction and operation time, which was basically very resembling to our consequence, except to lingual flap (not evaluated). Also, Sudarshan et al (2011) [11] showed that Meloxicam is an appropriate analgesic in postoperative complications (pain and swelling) than Diclofenac potassium with prolonged analgesia and low side effects, which was analogous to our consequence.
It may be virtually impossible to preview how someone will behave concerning pain after third molar surgery since, pain can have several modulators and that can range from sex, age, psychological status, previous pain experience, patient's daily medicines and habits, surgical site, health status, the surgery trauma itself and also the postoperative prescriptions [15].
Conclusion. This study showed the potential suitability for the management of our patients who have undergone oral surgical procedures. Third molar extraction performed in maxilla and mandible is unequal concerning pain response. Higher pain complains could be expected for patients who have difficult mandibular surgery and that means increase of trauma and procedure time spent.
In this study, prescribed Meloxicam for three days was preferably due to the low side effects in compare with Diclofenac potassium. According to our research, surgeon must be prescribing antibiotics (Amoxicillin/ Clavulanic acid) for all patients with ostectomy or ostectomy and odontotomy procedure in open extraction lower third molar.
Figure 2. Mean pain scores for first to third days after third molar surgery (n=100).
Figure 3. Mandible mean pain scores for first to third days according to teeth position(n=100).
Figure 4. Maxilla mean pain scores for first to third days according to teeth position (n=100).
Mandible teeth position/type (n =55).
3.6-
3.3-
3- O--" N. ~~~ --о
2.7- ...O
2.4-
2.1-
58 1 1 &<"..... H
1.20.9- V N x>-------- --o
1 2 Day 1 Day 2 3 Day 3
—Just crown formed — 2/3 root formed —Ventrical
Mesioangular —Distoangular
Maxilla teeth position/type (n=55).
1.81.51.20.90.60.30-
O
o. \
1 1 i 2 1 3
Day 1 Day 2 Day 3
—Just crown formed -2/3 root formed .....Ventrical
---Mesioangular -Distoangular ......Transverse
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УДК 616.314.9:615.327
ВИДАЛЕННЯ ТРЕТЬОГО МОЛЯРА ТА ЙОГО ЗВ'ЯЗОК З1 СТУПЕНЕМ БОЛЮ Масуд KiaHi, Панькевич А. I.
Резюме. Трет1 моляри, або «зуби мудрости починають формуватися у 9-10 роюв, формування коронки за-вершуеться приблизно у 14 роюв, а у останн1 роки п1дглткового в1ку починають перемщення у кютц1 i лише у вц вщ 16 до 25 роюв з'являються в ротк Через те, що ц зуби часто мають неправильну форму та pозмipи, вони мо-жуть займати неправильне положення, недостатньо пщцаються ппеычним заходам, тому швидко уражаються каpiесом та його ускладненнями. 1х консервативне л^вання, як правило е безперспективним, тому одним з основних методiв залишаеться видалення. Пюля хipуpгiчних маыпуляцм нерщко виникають ускладнення.
Метою даного доошдження стало поpiвняння ефективност диклофенаку натрю та мелоксикаму на ыве-лювання пюляоперацмного болю, набряку пюля атипового видалення нижнього i верхнього третього моляра.
Вибipка складалася з 100 пащенпв. Це дослщження показало потенцмну придатнють мелоксикама i дикло-фенаку натрю для зниження больового синдрому наших пащенпв, що перенесли хipуpгiчнi процедуру атипового видалення зуба мудрость
У цьому дослщжены, показано, що застосування Мелоксикаму дозволяе зменшити Ытенсивнють болю про-тягом пюляоперацмного перюду i не супроводжуеться побiчними ефектами, тод^ як диклофенак натрю мае бтьш виражений знеболюючий ефект. За даними нашого дослщження, хipуpг повинен застосовувати антибюти-ки (амоксицилЫ з клавулановою кислотою) у вЫх пащенпв з проведеною остеотомiею пюля операцп атипового видалення зуба мудрост на нижнм щелет, що не е обов'язковим при видаленн зуба на верхнм щелепк Kлючовi слова: третм корЫний зуб, бть, диклофенак натрю, Мелоксикам, хipуpгiчна стоматолопя.
УДК 616.314.9:615.327
УДАЛЕНИЕ ТРЕТЬЕГО МОЛЯРА И ЕГО СВЯЗЬ СО СТЕПЕНЬЮ БОЛИ Масуд Киани, Панькевич А. И.
Резюме. Третьи моляры, или «зубы мудрости» начинают формироваться в 9-10 лет, формирование коронки завершается примерно в 14 лет, а в последние годы подросткового возраста начинают перемещение
в кости и только в возрасте от 16 до 25 лет появляются во рту. Так как эти зубы часто имеют неправильную форму и размеры, они могут занимать неправильное положение, недостаточно поддаются гигиеническим мероприятиям, поэтому быстро поражаются кариесом и его осложнениями. Их консервативное лечение, как правило, является бесперспективным, поэтому одним из основных методов остается удаление. После хирургических манипуляций нередко возникают осложнения.
Целью данного исследования стало сравнение эффективности диклофенака натрия и мелоксикама на нивелирование послеоперационной боли, отека после атипичного удаления нижнего и верхнего третьего моляра.
Выборка состояла из 100 пациентов. Это исследование показало потенциальную пригодность мелоксикама и диклофенака натрия для снижения болевого синдрома наших пациентов, перенесших хирургическую процедуру атипичного удаления зуба мудрости.
В этом исследовании, показано, что применение мелоксикама позволяет уменьшить интенсивность боли в течение послеоперационного периода и не сопровождается побочными эффектами, тогда, как диклофенак натрия имеет более выраженный обезболивающий эффект. По данным нашего исследования, хирург должен применять антибиотики (амоксициллин с клавулановой кислотой) у всех пациентов с проведенной остеотомией после операции атипичного удаления зуба мудрости на нижней челюсти, что не является обязательным при удалении зуба на верхней челюсти.
Ключевые слова: третий коренной зуб, боль, диклофенак натрия, Мелоксикам, хирургическая стоматология.
UDC 616.314.9:615.327
EXTRACTION OF THIRD MOLAR AND IT'S RELATIONSHIP WITH GRADING OF PAIN
Masoud Kiani, Pankevych A. I.
Abstract. Four types of teeth, being the eruption after another teeth are called wisdom teeth or third molars, start at the approximate age is 9 till 10 years old in the jawbone and crown completed in 14 years old and in the last years of adolescence begin to eruption inside the bone and after the age of 16 till 25 years old appear in the mouth. Due to lack of a natural form of wisdom teeth like many other teeth and perch at the end of the jaw and do not clean them when brushing, so vulnerable and usually sooner than other teeth are caries. Restoration and filling wisdom teeth are difficult; so, to extract the wisdom teeth.
The aim of this study was to compare the effects of Diclofenac potassium and Meloxicam on postoperative pain, swelling, etc. after surgical extraction of lower and upper third molars.
Third molar surgery is one of the most common procedures performed in oral surgery. Nevertheless, this procedure requires accurate planning and surgical skills. With surgical procedures in general, complications can always arise. Extraction of teeth is a common dental procedure. After tooth extraction the patient may experience pain, and there is a varying degree of severity between patients.
Postpone the extraction of third molar into old age may cause the following complications:
- Reduce recovery after tooth extractions;
- Dental caries on adjacent tooth;
- The possibility of welding jaw teeth;
- The roots were thicker, with increase age and may be more difficult tooth extractions.
Also, generally complications of removal wisdom teeth are : pain, swelling, trismus, malaise, hemorrhage, fractures of the mandible and the maxilla, damage to adjacent teeth, alveolar osteitis, periodontal damage, soft-tissue infection and temporary paresthesia (numbness of the lips, tongue and cheek).
Postoperative pain is related significantly to the amount of surgical trauma. Surgical removal of bony impactions and osseous periodontal surgery are more traumatic and produce more intense pain when compared with simple uncomplicated tooth extraction.
Most of the literature focuses on postoperative pain after surgical removal of impacted third molars or on the effectiveness of different pharmaceutical options in combating postsurgical pain.
A thorough understanding of the complications associated with this procedure will enable the practitioner to identify and counsel high-risk patients, appropriately manage more common complications and be cognizant of less common sequelae and the most effective methods of management.
Surgical extraction of third molars is often accompanied by complications. So, careful surgical technique and scrupulous perioperative care can minimize the frequency of complications and limit their severity. Third molar extraction performed in maxilla and mandible is unequal concerning pain response. Higher pain complains could be expected for patients who have difficult mandibular surgery and that means increase of trauma and procedure time spent.
The sample consisted of 100 consecutive patients. This study showed the potential suitability of Meloxicam and Diclofenac potassium for the management of our patients who have undergone oral surgical procedures.
In this study, prescribed Meloxicam for three days was preferably due to the low side effects in compare with Diclofenac potassium. According to our research, surgeon must be prescribing antibiotics (Amoxicillin/Clavulanic acid) for all patients with ostectomy or ostectomy and odontotomy procedure in open extraction lower third molar.
Keywords: third molar tooth, pain, Diclofenac potassium, Meloxicam, surgical dentistry.
Рецензент - проф. Авет1ков Д. С.
Стаття надшшла 01.03.2016 року
