DENTOALVEOLAR SURGERY
Pain With Pericoronitis Affects Quality of Life Caitlin B. L. Magraw, DDS,* Brent Golden, DDS, MD,y Ceib Phillips, PhD, MPH,z Dana T. Tang, DDS,x Joshua Munson, BA,k Blake P. Nelson,{ and Raymond P. White Jr, DDS, PhD# Purpose:
To assess the association between patients’ pericoronitis pain symptoms and quality-of-life (QOL) outcomes for lifestyle and oral function.
Patients and Methods:
Subjects (American Society of Anesthesiologists health risk assessment level I or II) with mild symptoms of pericoronitis were enrolled in a study approved by the institutional review board and asked to complete a QOL instrument specifically for third molar problems covering lifestyle, oral function, and pain. Subjects assessed lifestyle and oral function using a 5-point Likert-type scale, ranging from ‘‘no trouble’’ (score, 1) to ‘‘lots of trouble’’ (score, 5), and worst and average pain using a 7-point Likert-type scale, ranging from ‘‘no pain’’ (score, 1) to ‘‘worst pain imaginable’’ (score, 7). Pain levels reported at enrollment were compared with QOL outcomes for lifestyle and oral function using Spearman correlation coefficients. Correlations of at least 0.6 were considered clinically quite important, and correlations of at least 0.4 were considered clinically important. Associations between these outcome measurements were considered statistically significant at a P value less than .05.
Results:
Most of the 113 subjects were Caucasian (51%), women (56%), 23 years old or younger (58%), and well educated (91% with at least some college). Mean pain levels standard deviation were low (worst pain, 3.3 1.5; average pain, 2.4 1.2). All pain outcomes were significantly associated with items in the lifestyle and oral function domains (P < .01). Clinically important correlations were seen between pain outcomes and daily routine, social life, eating a regular diet, chewing food, and talking (P < .0001).
Conclusions: Clinically important correlations existed between subjects’ pericoronitis pain and lifestyle and oral function, associations not often considered by clinicians or policy makers. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:7-12, 2015
Clinicians most often associate pericoronitis affecting third molars with pain. For those afflicted, pain is the symptom that often prompts them to seek treatment.1-3 Because pain results from an individual’s immune inflammatory response to anaerobic bacteria
colonized in biofilm that cannot be shed from symptomatic third molars, pericoronitis is better termed symptomatic periodontal inflammatory disease. However, symptoms from inflammation usually involve more than pain alone.4 Clinicians less
Received from the School of Dentistry, University of North Carolina,
Surgeons, and the Department of Oral and Maxillofacial Surgery,
Chapel Hill, NC. *Resident, Department of Oral and Maxillofacial Surgery.
University of North Carolina. Conflict of Interest Disclosures: None of the authors reported any
yClinical
Assistant
Professor,
Department
of
Oral
and
disclosures.
Maxillofacial Surgery.
Address correspondence and reprint requests to Dr White:
zProfessor, Department of Orthodontics.
Department of Oral and Maxillofacial Surgery, School of Dentistry,
xSenior Resident, Department of Orthodontics.
University of North Carolina, Chapel Hill, NC 27599-7450; e-mail:
kDental Student.
[email protected]
{Dental Student.
Received April 10 2014
#Dalton L. McMichael Distinguished Professor, Department of Oral and Maxillofacial Surgery.
Accepted June 30 2014 Ó 2015 American Association of Oral and Maxillofacial Surgeons
Registered ClinicalTrials.gov identifier, NCT 01882270.
0278-2391/14/01117-3
This work was supported by the Oral and Maxillofacial Surgery
http://dx.doi.org/10.1016/j.joms.2014.06.458
Foundation, the American Association of Oral and Maxillofacial
7
8
PERICORONITIS PAIN AFFECTS QUALITY OF LIFE
often consider the influence that pain can have on quality-of-life (QOL) domains of lifestyle and oral function. The possible association between pain symptoms and other QOL outcomes needs further study and clarification. McNutt et al5 assessed pain and other QOL outcomes in patients with mild symptoms of pericoronitis affecting third molars. Most patients reported the worst pain they experienced in the week before enrollment to be at least moderate. In addition, a clinically important percentage of patients reported problems with oral function. Almost one fourth of patients reported that they had quite a bit or lots of difficulty with eating and 19% had quite a bit or lots of difficulty with chewing. Bradshaw et al6 evaluated patients with mild symptoms of pericoronitis who elected to have all third molars removed. In addition to symptoms of pain, one fifth of patients reported difficulty with oral function (quite a bit or lots of difficulty) in the past week, specifically with chewing foods and eating their regular diet. Three months after surgery, a major improvement in QOL outcomes was reported. For example, 3 months after surgery, 95% and 93% of patients reported having no trouble with eating and chewing, respectively. Pain with pericoronitis does seem to motivate affected patients to seek treatment. Slade et al7 reported that 37% of 480 patients treated in community practices or academic clinical centers had sufficient pain or swelling in the 3 months before surgery to seek removal of third molars before symptoms occurred again. Excluding the 2 pain items, one fourth of the symptomatic patients reported on the Oral Health Impact Profile (OHIP-14) before surgery that their lifestyle activities were affected fairly often or very often by the condition.7 Tang et al8 reported that in patients with mild symptoms of pericoronitis, pain was one reason for electing third molar removal. However, negative QOL outcomes for lifestyle and oral function also were associated with an early decision for surgical removal of third molars within a few months of enrollment. The purpose of this study was to further the understanding of how pericoronitis affects afflicted patients from a QOL standpoint. The authors hypothesized that there would be an association between patients’ reported pain symptoms with pericoronitis and QOL outcomes for lifestyle and oral function. More specifically, they hoped to elucidate the extent of the disability from pericoronitis even with mild symptoms.
Patients and Methods STUDY DESIGN
Data for analyses were obtained at enrollment from a sample of subjects with mild symptoms of pericoroni-
tis enrolled in a longitudinal study designed to better understand the clinical signs and symptoms of the condition affecting mandibular third molars. Subjects were recruited at a single academic clinical center (University of North Carolina, Chapel Hill) for an institutional review board–approved, prospective, exploratory clinical study. The study population was composed of patients presenting for evaluation and management of mild pericoronitis from 2006 through 2012. Inclusion criteria specified that subjects be 18 to 35 years old, have an American Society of Anesthesiologists health risk assessment of level I or II, and have mild signs or symptoms of pericoronitis, which included spontaneous pain, purulence or drainage, or localized swelling, affecting at least 1 mandibular third molar. Those with severe signs or symptoms of pericoronitis, such as limited mouth opening, dysphagia, temperature higher than 101 F, facial swelling or cellulitis, or severe uncontrolled discomfort, were excluded. In addition, those with a medical condition contraindicating periodontal probing, an acute illness, a body mass index greater than 29 kg/m2, a history of antibiotic treatment within the past 2 months, generalized Class IV periodontal disease according to the American Academy of Periodontology, and tobacco use were excluded. DATA COLLECTION METHODS
After consent to participate in the study was obtained, demographic and QOL data were collected from each subject. To assess the impact of mild pericoronitis on quality of life in the week before enrollment, subjects at enrollment were asked to complete the Health Related Quality of Life instrument developed by Shugars et al9 specifically for third molar problems. The instrument covers 3 QOL domains: lifestyle, oral function, and pain. Lifestyle relates to the ability to sleep, carry out a daily routine, take part in a social life, and participate in sports or recreation. Oral function deals specifically with the ability to eat a regular diet, chew food, open one’s mouth, and talk. Patients were asked to assess oral function and lifestyle outcomes using a 5-point Likert-type scale, ranging from no trouble (score, 1) to lots of trouble (score, 5). Because pain is the predominant symptom of pericoronitis, patients were asked to assess worst and average pain using a 7-point Likert-type scale. The 7-point Likerttype scale for pain ranged from no pain (score, 1) to worst pain imaginable (score, 7). In addition, the impact of pericoronitis symptoms on quality of life over a longer time frame (3-month interval before study enrollment) was analyzed using the OHIP14, an instrument designed to record responses on the effect of oral conditions on overall health and wellbeing.10 Each item was coded as 0 (never), 1 (hardly ever), 2 (occasionally), 3 (fairly often), or 4 (very often).
9
MAGRAW ET AL
Overall severity affecting overall health for each subject was computed as the sum of all OHIP-14 scores (maximum score, 56). An extent score was computed as the number of OHIP-14 items reported fairly often or very often by each subject (maximum score, 14). Pain severity for each subject was computed as the sum of responses to the 2 OHIP pain items (maximum score, 8). DATA ANALYSES
The protocols described by White et al11 were used for data entry and data management. Subjects’ reports at enrollment for measurements of pain in the previous week (average pain and worst pain; Likert-type scale, 1 to 7) were compared with the outcomes for QOL domains for lifestyle and oral function using Spearman correlation coefficients (rs). OHIP-14 items for severity score and physical pain in the 3 months before enrollment were compared with the outcomes for the same time frame for each of the remaining 6 OHIP-14 dimensions using Spearman correlation coefficients. Positive correlations of at least 0.6 were considered clinically quite important and positive correlations of at least 0.4 were considered clinically important. Associations between these outcome measurements were considered statistically significant at a P value less than .05.
Results Most of the 113 enrolled subjects were Caucasian (51%), women (56%), 23 years old or younger (58%), and well educated (91% had some college experience; Table 1). Pain levels in the week before enrollment were at the lower end of the 7-point Likert-type scale (mean standard deviation; worst pain, 3.3 1.5; average pain, 2.4 1.2). Only 23% of subjects reported the worst pain as severe (score, 5 to 7) and 5% reported average pain as severe (score, 5 to 7; Fig 1). For the 3 months before enrollment, subjects’ mean OHIP-14 score for overall severity was 12.5 8.4 (22 of a possible score of 56; Fig 2). Mean OHIP-14 extent score was 1.4 2.0 (10% of a possible 14). Pain severity score was 4.3 2.0 (54% of a possible 8; Fig 2). At least one fifth of subjects reported items in the lifestyle domain as more than no trouble (daily routine, 32%; social life, 20%; sleeping, 29%; Table 2). Items in the oral function domain were more likely to be reported as more than no trouble (mouth opening, 32%; eating a regular diet, 60%; chewing food, 63%; Table 2). Likert-type scale pain outcomes for worst pain and average pain in the week before enrollment were significantly associated with all items in the lifestyle domain (daily routine, social life, sports or recreation, and sleeping; P < .01). Clinically important correlations were seen between worst pain and most items
Table 1. DEMOGRAPHIC CHARACTERISTICS OF ALL PATIENTS AT ENROLLMENT (N = 113)
Age (yr) 23 or younger greater than 23 Gender Female Male Ethnicity Caucasian Non-Caucasian African American Asian Hispanic Other Education At least some college education Less than college
66 (58.4) 47 (41.6) 63 (55.8) 50 (44.3) 58 (51.3) 55 (48.7) 26 (23.0) 14 (12.4) 6 (5.3) 9 (8.0) 103 (91.2) 10 (8.8)
Note: Data are presented as number (column percentage). Total percentage may not add up to 100% because percentages were rounded to the nearest 10th decimal place. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
in the lifestyle domain, except for sports or recreation (Table 3). For example, the correlation coefficient between worst pain and daily routine was 0.54 and that between average pain and social life was 0.43. Likert-type scale pain outcomes for worst pain and average pain in the week before enrollment were significantly associated with all items in the oral function domain (eating a regular diet, chewing food, mouth opening, and talking; P < .0001). Clinically very important correlations were seen between all pain outcomes and eating a regular diet and chewing food, whereas clinically important correlations were seen between worst pain and mouth opening and talking (Table 3). For example, the correlation coefficient between worst pain and chewing food was 0.70 and that between average pain and eating a regular diet was 0.67. OHIP-14 pain outcomes for severity score and physical pain in the 3 months before enrollment were significantly associated with all other OHIP-14 dimensions (functional limitation, psychological discomfort, physical disability, psychological disability, social disability, and handicap; P < .0001). Clinically important correlations were seen between pain outcomes and functional limitation, psychological discomfort, physical disability, psychological disability, and social disability (Table 4). For example, the correlation coefficient between severity score and physical disability was 0.72 and that between physical pain and social disability was 0.51.
10
PERICORONITIS PAIN AFFECTS QUALITY OF LIFE
Table 2. PATIENTS’ QUALITY-OF-LIFE MEASUREMENTS IN THE WEEK BEFORE ENROLLMENT (N = 113)
FIGURE 1. Distribution of patients (N = 113) reporting worst pain or average pain levels on a 7-point Likert-type scale anchored by the terms no pain and worst pain imaginable. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
Discussion Clinicians and afflicted patients associate pericoronitis with pain, a periodontal inflammatory condition most often affecting lower third molars. The present data enhance the understanding of the impact of peri-
Trouble with eating No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with chewing* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with talking* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with mouth opening No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with sleeping* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with going about daily routine No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with taking part in a social life No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with participating in sports* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5)
45 (39.8) 24 (21.2) 44 (38.9) 41 (36.6) 30 (26.8) 41 (36.6) 94 (83.9) 15 (13.4) 3 (2.7) 77 (68.1) 24 (21.2) 12 (10.6) 79 (70.5) 19 (17.0) 14 (12.5) 77 (68.1) 24 (21.2) 12 (10.6) 90 (79.7) 14 (12.4) 9 (8.0) 97 (86.6) 9 (8.0) 6 (5.4)
Note: Data are presented as number (column percentage). Total percentage may not add up to 100% because percentages were rounded to the nearest 10th decimal place. * Data missing for 1 subject. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
FIGURE 2. Distribution of patients (N = 113) reporting OHIP-14 scores for the 3 months before enrollment as mean percentages of maximum scores for overall severity (sum of all OHIP-14 scores; maximum score, 56), extent (number of OHIP-14 items reported fairly often or very often by each patient; maximum score, 14), and pain severity (sum of responses to the 2 OHIP pain items; maximum score, 8). OHIP-14, Oral Health Impact Profile. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
coronitis on quality of life beyond symptoms of pain. Clinically important correlations existed between assessments of subjects’ pain outcomes and those in the lifestyle and oral function domains in the week before enrollment and almost all OHIP-14 dimensions in the 3 months before enrollment. For example, for an rs value of at least 0.4, at least 16% of the variability in oral function and lifestyle was explained by pain; for an rs value of at least 0.6, 36% of the variability was explained by pain. These outcomes underscore for clinicians and the public the extent of the disability from pericoronitis even with mild symptoms. The oral function domain items of eating a regular diet and chewing food appeared to be more highly correlated with pain outcomes (rs $ 0.64 designated
11
MAGRAW ET AL
Table 3. SPEARMAN CORRELATION COEFFICIENTS COMPARING REPORTED WORST AND AVERAGE PAIN LEVELS ON A 7-POINT LIKERT-TYPE SCALE IN THE WEEK BEFORE ENROLLMENT WITH ITEMS IN THE LIFESTYLE AND ORAL FUNCTION DOMAINS
Spearman Correlation Coefficients for Lifestyle Quality-of-Life Domain
Likert-Type Scale
Daily Routine
Social Life
Sports or Recreation
Worst pain Average pain
0.54* 0.46*
0.45* 0.43*
0.37 0.28
Spearman Correlation Coefficients for Oral Function Quality-of-Life Domain
Sleeping
Eating a Regular Diet
Chewing Food
Mouth Opening
Talking
0.47* 0.31
0.66y 0.67y
0.70y 0.64y
0.44* 0.38
0.41* 0.44*
Note: The scale was anchored by the terms no pain and worst pain imaginable with items in the lifestyle domain (N = 113) and the oral function domain (N = 113). All associations between these outcome measurements were considered significant (P < .01 for lifestyle domain; P < .0001 for oral function domain). * Clinically important (rs > 0.4; P < .0001). y Clinically quite important (rs > 0.6; P < .0001). Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
clinically quite important) than items in the lifestyle domain (rs < 0.55 designated clinically important). These data suggest that pericoronitis affects oral function more substantially than reported by McNutt et al5 and Bradshaw et al.6 Data from subjects’ reports on the OHIP-14 instrument expand the understanding of the impact of pain with pericoronitis on oral health and quality of life over a longer time frame, that is, 3 months before enrollment. The physical disability dimension (unsatisfactory diet and interrupted meals) was most highly correlated with pain severity (rs > 0.70). All other OHIP-14 dimensions except handicap were correlated with pain severity (rs > 0.40). Data from the OHIP-14 instrument echo the findings of the third molar QOL instrument’s lifestyle and oral function domains, providing further evidence that oral function is impaired to a greater degree than lifestyle. McGrath et al12 used the OHIP-14 instrument to evaluate changes in oral health-related quality of life
after third molar removal and found an improvement in oral health-related quality of life at 3 and 6 months after surgery. The present data are consistent with the data of McGrath et al12 and Bradshaw et al,6 suggesting that the resolution of pain would likely result in an improvement in overall health and well-being and might be expected if the present subjects had their third molars extracted, which most patients opted to do.6,8,12 There are several limitations to this study. First, the present sample consisted of young, well-educated, somewhat diverse subjects, typical of those presenting to an academic center in a university community and not necessarily representative of the US population who may have pericoronitis. Second, the present study excluded subjects with moderate and severe symptoms of pericoronitis because it would not be ethical to ask these patients to retain their third molars in a longitudinal study without active treatment. The inflammatory response to pathogens may differ for
Table 4. SPEARMAN CORRELATION COEFFICIENTS COMPARING OHIP-14 SCORES FOR PAIN SEVERITY IN THE 3 MONTHS BEFORE ENROLLMENT WITH ALL OTHER DIMENSIONS IN THE OHIP-14 PROFILE (N = 113)
Spearman Correlation Coefficients for OHIP-14 Dimensions OHIP-14 Pain Dimensions
Functional Limitation
Psychological Discomfort
Physical Disability
Psychological Disability
Social Disability
Handicap
Severity score Physical pain
0.42* 0.43*
0.41* 0.41*
0.72y 0.75y
0.44* 0.45*
0.48* 0.51*
0.39 0.38
Note: All associations between these outcome measurements were significant (P < .0001). Abbreviation: OHIP-14, Oral Health Impact Profile. * Clinically important (rs > 0.4; P < .0001). y Clinically quite important (rs > 0.6; P < .0001). Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
12 those with more severe symptoms of pericoronitis. More severe pericoronitis symptoms could have a greater impact on quality of life and the resulting decision and timing for third molar removal in affected patients.13 Third, the present study excluded subjects with medical conditions contraindicating periodontal probing, antibiotic use, or generalized periodontal disease. Fourth, subjects with a body mass index greater than 29 kg/m2 or tobacco use were excluded secondary to concerns that circulating inflammatory mediators from these conditions could affect the oral inflammatory response.14,15 Although the number of subjects in this study was adequate to show statistically significant correlations between outcomes, the small number of subjects affected with lifestyle and oral function 5-point Likert scores of 3 to 5 limits 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 experience pericoronitis symptoms, making enrollment of adequate numbers of patients protracted.3,16,17 This issue is reflected in the 6-year time frame required to enroll subjects for this study. The report by Tang et al8 suggested that the chronic nature of pericoronitis may be difficult to document because patients appear to prefer to have third molars removed on average within 3 months, rather than wait for symptoms to worsen or recur. Although the instrument described by Shugars et al9 was designed specifically for third molar problems and quality of life, the OHIP-14 instrument is a more global oral QOL instrument designed for all oral health conditions and quality of life usually covering a longer time frame (#1 yr).9,10 Clinicians can use these data to better understand the impact of pericoronitis symptoms on various aspects of lifestyle and oral function beyond the symptom of pain. Furthermore, these data allow clinicians to recognize that even patients presenting with mild symptoms of pericoronitis may have had symptoms for a prolonged period, perhaps at least 3 months. This is consistent with the chronic, episodic nature of pericoronitis. Appreciating the potential recurring aspect of the disease process and the impact on various QOL outcomes is important for patients and health policy makers with the potential to affect future clinical guidelines. For these reasons, the authors believe the most effective treatment of pericoronitis is removal of third molars.6,18
PERICORONITIS PAIN AFFECTS QUALITY OF LIFE
Acknowledgments The authors thank volunteers who participated in this study. The authors also thank Ms Debora Price for her assistance in managing the data in this project and Ms Tiffany Hambright for her assistance as the clinical coordinator.
Press Release This article’s Press Release can be found, in the online version, at http://dx.doi.org/10.1016/j.joms. 2014.06.458.
References 1. Kay LW: Investigations into the nature of pericoronitis. Br J Oral Surg 3:188, 1966 2. Vent€a I, Turtola L, Murtomaa H, et al: Third molars as an acute problem in Finnish university students. Oral Surg Oral Med Oral Pathol 76:135, 1993 3. Leone SA, Edenfield MJ: Third molars and acute pericoronitis: A military problem. Mil Med 152:146, 1987 4. Offenbacher S, Barros SP, Singer RE, et al: Periodontal disease at the biofilm-gingival interface. J Periodontol 78:1911, 2007 5. 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 6. 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 7. Slade GD, Foy SP, Shugars DA, et al: The impact of third molar symptoms, pain and swelling, on oral health related quality of life. J Oral Maxillofac Surg 63:1118, 2004 8. Tang DT, Phillips C, Proffit WR, et al: Effect of quality of life measures on the decision to have third molars removed in subjects with mild pericoronitis symptoms. J Oral Maxillofac Surg 72: 1235, 2014 9. 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 10. Slade GD, Spencer AJ: Development and evaluation of the oral health impact profile. Commun Dent Health 11:3, 1994 11. 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 12. McGrath C, Comfort MB, Lo EC, et al: Can third molar surgery improve quality of life? A 6-month cohort study. J Oral Maxillofac Surg 61:759, 2003 13. 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 14. Visser M, Bouter LM, McQuillan GM, et al: Elevated C-reactive protein levels in overweight and obese adults. JAMA 282:2131, 1999 15. Arnson Y, Shoenfeld Y, Amital H: Effects of tobacco smoke on immunity, inflammation and autoimmunity. J Autoimmun 34: J258, 2010 16. Berge TI: Third molars in Norwegian general dental practice. Acta Odontol Scand 50:17, 1992 17. 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 18. Dicus C, Blakey G, Faulk-Eggleston J, et al: Second molar periodontal inflammatory disease after third molar removal in young adults. J Oral Maxillofac Surg 68:3000, 2010
Pain With Pericoronitis Affects Quality of Life Caitlin B. L. Magraw, DDS,* Brent Golden, DDS, MD,y Ceib Phillips, PhD, MPH,z Dana T. Tang, DDS,x Joshua Munson, BA,k Blake P. Nelson,{ and Raymond P. White Jr, DDS, PhD# Purpose:
To assess the association between patients’ pericoronitis pain symptoms and quality-of-life (QOL) outcomes for lifestyle and oral function.
Patients and Methods:
Subjects (American Society of Anesthesiologists health risk assessment level I or II) with mild symptoms of pericoronitis were enrolled in a study approved by the institutional review board and asked to complete a QOL instrument specifically for third molar problems covering lifestyle, oral function, and pain. Subjects assessed lifestyle and oral function using a 5-point Likert-type scale, ranging from ‘‘no trouble’’ (score, 1) to ‘‘lots of trouble’’ (score, 5), and worst and average pain using a 7-point Likert-type scale, ranging from ‘‘no pain’’ (score, 1) to ‘‘worst pain imaginable’’ (score, 7). Pain levels reported at enrollment were compared with QOL outcomes for lifestyle and oral function using Spearman correlation coefficients. Correlations of at least 0.6 were considered clinically quite important, and correlations of at least 0.4 were considered clinically important. Associations between these outcome measurements were considered statistically significant at a P value less than .05.
Results:
Most of the 113 subjects were Caucasian (51%), women (56%), 23 years old or younger (58%), and well educated (91% with at least some college). Mean pain levels standard deviation were low (worst pain, 3.3 1.5; average pain, 2.4 1.2). All pain outcomes were significantly associated with items in the lifestyle and oral function domains (P < .01). Clinically important correlations were seen between pain outcomes and daily routine, social life, eating a regular diet, chewing food, and talking (P < .0001).
Conclusions: Clinically important correlations existed between subjects’ pericoronitis pain and lifestyle and oral function, associations not often considered by clinicians or policy makers. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:7-12, 2015
Clinicians most often associate pericoronitis affecting third molars with pain. For those afflicted, pain is the symptom that often prompts them to seek treatment.1-3 Because pain results from an individual’s immune inflammatory response to anaerobic bacteria
colonized in biofilm that cannot be shed from symptomatic third molars, pericoronitis is better termed symptomatic periodontal inflammatory disease. However, symptoms from inflammation usually involve more than pain alone.4 Clinicians less
Received from the School of Dentistry, University of North Carolina,
Surgeons, and the Department of Oral and Maxillofacial Surgery,
Chapel Hill, NC. *Resident, Department of Oral and Maxillofacial Surgery.
University of North Carolina. Conflict of Interest Disclosures: None of the authors reported any
yClinical
Assistant
Professor,
Department
of
Oral
and
disclosures.
Maxillofacial Surgery.
Address correspondence and reprint requests to Dr White:
zProfessor, Department of Orthodontics.
Department of Oral and Maxillofacial Surgery, School of Dentistry,
xSenior Resident, Department of Orthodontics.
University of North Carolina, Chapel Hill, NC 27599-7450; e-mail:
kDental Student.
[email protected]
{Dental Student.
Received April 10 2014
#Dalton L. McMichael Distinguished Professor, Department of Oral and Maxillofacial Surgery.
Accepted June 30 2014 Ó 2015 American Association of Oral and Maxillofacial Surgeons
Registered ClinicalTrials.gov identifier, NCT 01882270.
0278-2391/14/01117-3
This work was supported by the Oral and Maxillofacial Surgery
http://dx.doi.org/10.1016/j.joms.2014.06.458
Foundation, the American Association of Oral and Maxillofacial
7
8
PERICORONITIS PAIN AFFECTS QUALITY OF LIFE
often consider the influence that pain can have on quality-of-life (QOL) domains of lifestyle and oral function. The possible association between pain symptoms and other QOL outcomes needs further study and clarification. McNutt et al5 assessed pain and other QOL outcomes in patients with mild symptoms of pericoronitis affecting third molars. Most patients reported the worst pain they experienced in the week before enrollment to be at least moderate. In addition, a clinically important percentage of patients reported problems with oral function. Almost one fourth of patients reported that they had quite a bit or lots of difficulty with eating and 19% had quite a bit or lots of difficulty with chewing. Bradshaw et al6 evaluated patients with mild symptoms of pericoronitis who elected to have all third molars removed. In addition to symptoms of pain, one fifth of patients reported difficulty with oral function (quite a bit or lots of difficulty) in the past week, specifically with chewing foods and eating their regular diet. Three months after surgery, a major improvement in QOL outcomes was reported. For example, 3 months after surgery, 95% and 93% of patients reported having no trouble with eating and chewing, respectively. Pain with pericoronitis does seem to motivate affected patients to seek treatment. Slade et al7 reported that 37% of 480 patients treated in community practices or academic clinical centers had sufficient pain or swelling in the 3 months before surgery to seek removal of third molars before symptoms occurred again. Excluding the 2 pain items, one fourth of the symptomatic patients reported on the Oral Health Impact Profile (OHIP-14) before surgery that their lifestyle activities were affected fairly often or very often by the condition.7 Tang et al8 reported that in patients with mild symptoms of pericoronitis, pain was one reason for electing third molar removal. However, negative QOL outcomes for lifestyle and oral function also were associated with an early decision for surgical removal of third molars within a few months of enrollment. The purpose of this study was to further the understanding of how pericoronitis affects afflicted patients from a QOL standpoint. The authors hypothesized that there would be an association between patients’ reported pain symptoms with pericoronitis and QOL outcomes for lifestyle and oral function. More specifically, they hoped to elucidate the extent of the disability from pericoronitis even with mild symptoms.
Patients and Methods STUDY DESIGN
Data for analyses were obtained at enrollment from a sample of subjects with mild symptoms of pericoroni-
tis enrolled in a longitudinal study designed to better understand the clinical signs and symptoms of the condition affecting mandibular third molars. Subjects were recruited at a single academic clinical center (University of North Carolina, Chapel Hill) for an institutional review board–approved, prospective, exploratory clinical study. The study population was composed of patients presenting for evaluation and management of mild pericoronitis from 2006 through 2012. Inclusion criteria specified that subjects be 18 to 35 years old, have an American Society of Anesthesiologists health risk assessment of level I or II, and have mild signs or symptoms of pericoronitis, which included spontaneous pain, purulence or drainage, or localized swelling, affecting at least 1 mandibular third molar. Those with severe signs or symptoms of pericoronitis, such as limited mouth opening, dysphagia, temperature higher than 101 F, facial swelling or cellulitis, or severe uncontrolled discomfort, were excluded. In addition, those with a medical condition contraindicating periodontal probing, an acute illness, a body mass index greater than 29 kg/m2, a history of antibiotic treatment within the past 2 months, generalized Class IV periodontal disease according to the American Academy of Periodontology, and tobacco use were excluded. DATA COLLECTION METHODS
After consent to participate in the study was obtained, demographic and QOL data were collected from each subject. To assess the impact of mild pericoronitis on quality of life in the week before enrollment, subjects at enrollment were asked to complete the Health Related Quality of Life instrument developed by Shugars et al9 specifically for third molar problems. The instrument covers 3 QOL domains: lifestyle, oral function, and pain. Lifestyle relates to the ability to sleep, carry out a daily routine, take part in a social life, and participate in sports or recreation. Oral function deals specifically with the ability to eat a regular diet, chew food, open one’s mouth, and talk. Patients were asked to assess oral function and lifestyle outcomes using a 5-point Likert-type scale, ranging from no trouble (score, 1) to lots of trouble (score, 5). Because pain is the predominant symptom of pericoronitis, patients were asked to assess worst and average pain using a 7-point Likert-type scale. The 7-point Likerttype scale for pain ranged from no pain (score, 1) to worst pain imaginable (score, 7). In addition, the impact of pericoronitis symptoms on quality of life over a longer time frame (3-month interval before study enrollment) was analyzed using the OHIP14, an instrument designed to record responses on the effect of oral conditions on overall health and wellbeing.10 Each item was coded as 0 (never), 1 (hardly ever), 2 (occasionally), 3 (fairly often), or 4 (very often).
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Overall severity affecting overall health for each subject was computed as the sum of all OHIP-14 scores (maximum score, 56). An extent score was computed as the number of OHIP-14 items reported fairly often or very often by each subject (maximum score, 14). Pain severity for each subject was computed as the sum of responses to the 2 OHIP pain items (maximum score, 8). DATA ANALYSES
The protocols described by White et al11 were used for data entry and data management. Subjects’ reports at enrollment for measurements of pain in the previous week (average pain and worst pain; Likert-type scale, 1 to 7) were compared with the outcomes for QOL domains for lifestyle and oral function using Spearman correlation coefficients (rs). OHIP-14 items for severity score and physical pain in the 3 months before enrollment were compared with the outcomes for the same time frame for each of the remaining 6 OHIP-14 dimensions using Spearman correlation coefficients. Positive correlations of at least 0.6 were considered clinically quite important and positive correlations of at least 0.4 were considered clinically important. Associations between these outcome measurements were considered statistically significant at a P value less than .05.
Results Most of the 113 enrolled subjects were Caucasian (51%), women (56%), 23 years old or younger (58%), and well educated (91% had some college experience; Table 1). Pain levels in the week before enrollment were at the lower end of the 7-point Likert-type scale (mean standard deviation; worst pain, 3.3 1.5; average pain, 2.4 1.2). Only 23% of subjects reported the worst pain as severe (score, 5 to 7) and 5% reported average pain as severe (score, 5 to 7; Fig 1). For the 3 months before enrollment, subjects’ mean OHIP-14 score for overall severity was 12.5 8.4 (22 of a possible score of 56; Fig 2). Mean OHIP-14 extent score was 1.4 2.0 (10% of a possible 14). Pain severity score was 4.3 2.0 (54% of a possible 8; Fig 2). At least one fifth of subjects reported items in the lifestyle domain as more than no trouble (daily routine, 32%; social life, 20%; sleeping, 29%; Table 2). Items in the oral function domain were more likely to be reported as more than no trouble (mouth opening, 32%; eating a regular diet, 60%; chewing food, 63%; Table 2). Likert-type scale pain outcomes for worst pain and average pain in the week before enrollment were significantly associated with all items in the lifestyle domain (daily routine, social life, sports or recreation, and sleeping; P < .01). Clinically important correlations were seen between worst pain and most items
Table 1. DEMOGRAPHIC CHARACTERISTICS OF ALL PATIENTS AT ENROLLMENT (N = 113)
Age (yr) 23 or younger greater than 23 Gender Female Male Ethnicity Caucasian Non-Caucasian African American Asian Hispanic Other Education At least some college education Less than college
66 (58.4) 47 (41.6) 63 (55.8) 50 (44.3) 58 (51.3) 55 (48.7) 26 (23.0) 14 (12.4) 6 (5.3) 9 (8.0) 103 (91.2) 10 (8.8)
Note: Data are presented as number (column percentage). Total percentage may not add up to 100% because percentages were rounded to the nearest 10th decimal place. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
in the lifestyle domain, except for sports or recreation (Table 3). For example, the correlation coefficient between worst pain and daily routine was 0.54 and that between average pain and social life was 0.43. Likert-type scale pain outcomes for worst pain and average pain in the week before enrollment were significantly associated with all items in the oral function domain (eating a regular diet, chewing food, mouth opening, and talking; P < .0001). Clinically very important correlations were seen between all pain outcomes and eating a regular diet and chewing food, whereas clinically important correlations were seen between worst pain and mouth opening and talking (Table 3). For example, the correlation coefficient between worst pain and chewing food was 0.70 and that between average pain and eating a regular diet was 0.67. OHIP-14 pain outcomes for severity score and physical pain in the 3 months before enrollment were significantly associated with all other OHIP-14 dimensions (functional limitation, psychological discomfort, physical disability, psychological disability, social disability, and handicap; P < .0001). Clinically important correlations were seen between pain outcomes and functional limitation, psychological discomfort, physical disability, psychological disability, and social disability (Table 4). For example, the correlation coefficient between severity score and physical disability was 0.72 and that between physical pain and social disability was 0.51.
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PERICORONITIS PAIN AFFECTS QUALITY OF LIFE
Table 2. PATIENTS’ QUALITY-OF-LIFE MEASUREMENTS IN THE WEEK BEFORE ENROLLMENT (N = 113)
FIGURE 1. Distribution of patients (N = 113) reporting worst pain or average pain levels on a 7-point Likert-type scale anchored by the terms no pain and worst pain imaginable. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
Discussion Clinicians and afflicted patients associate pericoronitis with pain, a periodontal inflammatory condition most often affecting lower third molars. The present data enhance the understanding of the impact of peri-
Trouble with eating No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with chewing* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with talking* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with mouth opening No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with sleeping* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with going about daily routine No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with taking part in a social life No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5) Trouble with participating in sports* No trouble (score, 1) A little trouble (score, 2) More than a little trouble (scores, 3-5)
45 (39.8) 24 (21.2) 44 (38.9) 41 (36.6) 30 (26.8) 41 (36.6) 94 (83.9) 15 (13.4) 3 (2.7) 77 (68.1) 24 (21.2) 12 (10.6) 79 (70.5) 19 (17.0) 14 (12.5) 77 (68.1) 24 (21.2) 12 (10.6) 90 (79.7) 14 (12.4) 9 (8.0) 97 (86.6) 9 (8.0) 6 (5.4)
Note: Data are presented as number (column percentage). Total percentage may not add up to 100% because percentages were rounded to the nearest 10th decimal place. * Data missing for 1 subject. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
FIGURE 2. Distribution of patients (N = 113) reporting OHIP-14 scores for the 3 months before enrollment as mean percentages of maximum scores for overall severity (sum of all OHIP-14 scores; maximum score, 56), extent (number of OHIP-14 items reported fairly often or very often by each patient; maximum score, 14), and pain severity (sum of responses to the 2 OHIP pain items; maximum score, 8). OHIP-14, Oral Health Impact Profile. Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
coronitis on quality of life beyond symptoms of pain. Clinically important correlations existed between assessments of subjects’ pain outcomes and those in the lifestyle and oral function domains in the week before enrollment and almost all OHIP-14 dimensions in the 3 months before enrollment. For example, for an rs value of at least 0.4, at least 16% of the variability in oral function and lifestyle was explained by pain; for an rs value of at least 0.6, 36% of the variability was explained by pain. These outcomes underscore for clinicians and the public the extent of the disability from pericoronitis even with mild symptoms. The oral function domain items of eating a regular diet and chewing food appeared to be more highly correlated with pain outcomes (rs $ 0.64 designated
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Table 3. SPEARMAN CORRELATION COEFFICIENTS COMPARING REPORTED WORST AND AVERAGE PAIN LEVELS ON A 7-POINT LIKERT-TYPE SCALE IN THE WEEK BEFORE ENROLLMENT WITH ITEMS IN THE LIFESTYLE AND ORAL FUNCTION DOMAINS
Spearman Correlation Coefficients for Lifestyle Quality-of-Life Domain
Likert-Type Scale
Daily Routine
Social Life
Sports or Recreation
Worst pain Average pain
0.54* 0.46*
0.45* 0.43*
0.37 0.28
Spearman Correlation Coefficients for Oral Function Quality-of-Life Domain
Sleeping
Eating a Regular Diet
Chewing Food
Mouth Opening
Talking
0.47* 0.31
0.66y 0.67y
0.70y 0.64y
0.44* 0.38
0.41* 0.44*
Note: The scale was anchored by the terms no pain and worst pain imaginable with items in the lifestyle domain (N = 113) and the oral function domain (N = 113). All associations between these outcome measurements were considered significant (P < .01 for lifestyle domain; P < .0001 for oral function domain). * Clinically important (rs > 0.4; P < .0001). y Clinically quite important (rs > 0.6; P < .0001). Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
clinically quite important) than items in the lifestyle domain (rs < 0.55 designated clinically important). These data suggest that pericoronitis affects oral function more substantially than reported by McNutt et al5 and Bradshaw et al.6 Data from subjects’ reports on the OHIP-14 instrument expand the understanding of the impact of pain with pericoronitis on oral health and quality of life over a longer time frame, that is, 3 months before enrollment. The physical disability dimension (unsatisfactory diet and interrupted meals) was most highly correlated with pain severity (rs > 0.70). All other OHIP-14 dimensions except handicap were correlated with pain severity (rs > 0.40). Data from the OHIP-14 instrument echo the findings of the third molar QOL instrument’s lifestyle and oral function domains, providing further evidence that oral function is impaired to a greater degree than lifestyle. McGrath et al12 used the OHIP-14 instrument to evaluate changes in oral health-related quality of life
after third molar removal and found an improvement in oral health-related quality of life at 3 and 6 months after surgery. The present data are consistent with the data of McGrath et al12 and Bradshaw et al,6 suggesting that the resolution of pain would likely result in an improvement in overall health and well-being and might be expected if the present subjects had their third molars extracted, which most patients opted to do.6,8,12 There are several limitations to this study. First, the present sample consisted of young, well-educated, somewhat diverse subjects, typical of those presenting to an academic center in a university community and not necessarily representative of the US population who may have pericoronitis. Second, the present study excluded subjects with moderate and severe symptoms of pericoronitis because it would not be ethical to ask these patients to retain their third molars in a longitudinal study without active treatment. The inflammatory response to pathogens may differ for
Table 4. SPEARMAN CORRELATION COEFFICIENTS COMPARING OHIP-14 SCORES FOR PAIN SEVERITY IN THE 3 MONTHS BEFORE ENROLLMENT WITH ALL OTHER DIMENSIONS IN THE OHIP-14 PROFILE (N = 113)
Spearman Correlation Coefficients for OHIP-14 Dimensions OHIP-14 Pain Dimensions
Functional Limitation
Psychological Discomfort
Physical Disability
Psychological Disability
Social Disability
Handicap
Severity score Physical pain
0.42* 0.43*
0.41* 0.41*
0.72y 0.75y
0.44* 0.45*
0.48* 0.51*
0.39 0.38
Note: All associations between these outcome measurements were significant (P < .0001). Abbreviation: OHIP-14, Oral Health Impact Profile. * Clinically important (rs > 0.4; P < .0001). y Clinically quite important (rs > 0.6; P < .0001). Magraw et al. Pericoronitis Pain Affects Quality of Life. J Oral Maxillofac Surg 2015.
12 those with more severe symptoms of pericoronitis. More severe pericoronitis symptoms could have a greater impact on quality of life and the resulting decision and timing for third molar removal in affected patients.13 Third, the present study excluded subjects with medical conditions contraindicating periodontal probing, antibiotic use, or generalized periodontal disease. Fourth, subjects with a body mass index greater than 29 kg/m2 or tobacco use were excluded secondary to concerns that circulating inflammatory mediators from these conditions could affect the oral inflammatory response.14,15 Although the number of subjects in this study was adequate to show statistically significant correlations between outcomes, the small number of subjects affected with lifestyle and oral function 5-point Likert scores of 3 to 5 limits 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 experience pericoronitis symptoms, making enrollment of adequate numbers of patients protracted.3,16,17 This issue is reflected in the 6-year time frame required to enroll subjects for this study. The report by Tang et al8 suggested that the chronic nature of pericoronitis may be difficult to document because patients appear to prefer to have third molars removed on average within 3 months, rather than wait for symptoms to worsen or recur. Although the instrument described by Shugars et al9 was designed specifically for third molar problems and quality of life, the OHIP-14 instrument is a more global oral QOL instrument designed for all oral health conditions and quality of life usually covering a longer time frame (#1 yr).9,10 Clinicians can use these data to better understand the impact of pericoronitis symptoms on various aspects of lifestyle and oral function beyond the symptom of pain. Furthermore, these data allow clinicians to recognize that even patients presenting with mild symptoms of pericoronitis may have had symptoms for a prolonged period, perhaps at least 3 months. This is consistent with the chronic, episodic nature of pericoronitis. Appreciating the potential recurring aspect of the disease process and the impact on various QOL outcomes is important for patients and health policy makers with the potential to affect future clinical guidelines. For these reasons, the authors believe the most effective treatment of pericoronitis is removal of third molars.6,18
PERICORONITIS PAIN AFFECTS QUALITY OF LIFE
Acknowledgments The authors thank volunteers who participated in this study. The authors also thank Ms Debora Price for her assistance in managing the data in this project and Ms Tiffany Hambright for her assistance as the clinical coordinator.
Press Release This article’s Press Release can be found, in the online version, at http://dx.doi.org/10.1016/j.joms. 2014.06.458.
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