J Oral Maxilicfac
The Relationship Between the Indications for the Surgical Removal of Impacted Third Molars and the Incidence of Alveolar Osteitis TAREK L. AL-KHATEEB, NORMAN P. BUTLER,
BDS, PHD,* AKMAL MA, MDS, FFDRCSI,
I. EL-MARSAFI, FDSRCS(ENG),
DDS,T AND DRD(EDIN)$
Six hundred forty-two impacted third molars were surgically removed in 412 patients. Before surgery, each patient was assessed clinically and radiographically, and the reason for the removal of each tooth was specifically recorded. One hundred eighty-two of the impacted teeth were removed for prophylactic reasons and 460 for therapeutic reasons. As much as possible, standardization of the operating procedure and environment, and of the preoperative and postoperative regimens was observed. After surgery, each case was followed to determine the absence or presence of signs and symptoms of alveolar osteitis. It was found that several factors seem to contribute to the development of alveolar osteitis; however, the most significant related finding was that the reason for the extraction, that is, whether the extraction was undertaken for therapeutic or prophylactic reasons.
The reported incidence of alveolar osteitis (dry socket) following the removal of third molar teeth generally ranges from 0.5%’ to 16.6%,’ but figures as high as 37.5%3 or even 68.4%4 have also been reported. However, most authors report an incidence of 5% to 1O%.5-8 This variability in the reported incidence of alveolar osteitis may be owing to differences in diagnostic criteria, intraoperative and postoperative treatment of the extraction sites, patient age or medical status, and surgical technique or surgical skill. In the study reported here, as many as possible of these variables were standardized to enable measurements to be made of the sig-
nificance of the differing indications for removal of the impacted teeth. Accordingly, the sample was stratified into two main groups: those cases that required removal of third molar teeth for prophylactic reasons, and those that required the removal of third molar teeth for therapeutic reasons. Materials and Methods The removal of 642 impacted third molars was performed as an outpatient procedure by two members of the Dental Unit, King Abdulaziz University Hospital of Jeddah, Saudi Arabia. The sample contained 283 consecutive male patients (68.7%) and 129 consecutive female patients (3 1.3%). Their ages ranged from 16 to 53, with a mean of 32.5 years. Previously, each patient’s general medical history had been carefully recorded so as to exclude any medically compromised patients from the sample. The third molar teeth were examined clinically and radiographically and were considered to be impacted if they had been prevented from erupting into position because of malposition, lack of space, or other impediments. Of the patient sample, 56.6% underwent removal of one third molar, and 43.4%
Received from the College of Medicine and Allied Sciences, King Abdulaziz University (KAU), Jeddah. Saudi Arabia. * Assistant Professor, Dental School. t Senior Clinical Doctor. Dental Unit, KAU Hospital. $ Professor, Dental School. Address correspondence and reprint requests to Dr AlKhateeb: %Professor Denis M. O’Mullane, Department of Preventive and Paediatric Dentistry, University Dental School and Hospital, Wilton. Cork, Ireland. 0 1991 American geons
of Oral and Maxillofacial
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REMOVAL OF THIRD MOLARS AND ALVEOLAR
had two third molars removed. Eighty-five patients (20.6%) underwent removal of the two lower third molars and 20 patients (18%) underwent removal of the two upper third molars, and 20 patients (4.9%) underwent removal of one lower and one upper third molar. Each impacted tooth was removed in a separate session. Patients with more than two impactions were excluded from the study to eliminate, as far as possible, any bias which might have been created by individual aberrations. The exact indication for the extraction of each impacted tooth was recorded in the patients’ records. All surgical procedures were performed in the same clinic with similar instrumentation. Each impacted third molar was removed by one of two surgeons working together (the first and second authors), assisted on all occasions by the same surgical team. All other variables such as asepsis, type of local anesthetic, and preoperative and postoperative instructions were standardized. As far as possible, each tooth was removed by a standardized and planned technique. The incision was made buccally from a point between the first and second molar and continued posteriorly over the unexposed crown to a point 1.5 cm towards the buccal to enlarge the exposure of the impacted tooth. When necessary, an anterior vertical relieving incision was employed. Removal of bone as well as splitting of the tooth, when indicated, were done under continuous irrigation with sterile saline. After the extraction, the bony socket was trimmed as necessary. The flap was then repositioned over the alveolus and retained by two sutures. If either operator found it necessary to deviate from the planned and standardized technique, or if postoperative antibiotics
were considered advisable due to intraoperative complications, the case was excluded from the study. The presence or absence of alveolar osteitis was recorded at a follow-up visit 3 to 7 days after extraction. The criteria used in the diagnosis of alveolar osteitis were loss of blood clot, denuded alveolar bone, and pain requiring placement of an obtundent dressing. The results of this study were examined statistically by the x2 test. Results The total number of impacted third molar teeth surgically removed in this study was 642. The number removed for prophylactic reasons was 182 (28.3%) and for therapeutic reasons was 460 (71.7%). Of the 182 prophylactic extractions, 102 (56%) were undertaken for infection prophylaxis, 72 (39.6%) for prosthetic purposes, and 8 (4.4%) for orthodontic reasons. Similarly, of the 460 therapeutic extractions, 341 (74.1%) were removed because of infection, 93 (20.3%) because of caries, 17 (3.7%) because of cystic involvement, and 9 (1.9%) because of associated pain. The total incidence of alveolar osteitis following the removal of the 642 third molar teeth was 114 instances, or 17.8% of the total cases. However, there were 13 instances (7.1%) in the prophylactic group and 101 (21.9%) in the therapeutic group (Fig 1). This difference was statistically significant at P < .05(N = 642, df = 1, x2 = 19.5956). The incidence of alveolar osteitis in the subgroups is shown in Figure 2. In the prophylactic group, the incidence of alveolar osteitis was 9 out of a total of 102 impactions removed for infection prophylaxis and 4
600 I 500
N! U A 400 !!! k ; 300 0
kZl NORMAL HEALING f3 DRY SOCKET
FIGURE I. Distribution of normal healing and occurrence of alveolar osteitis within the groups.
: H 100
A PL EV RE
TR FIGURE 2. Percentage distribution of alveolar osteitis in the different indication groups.
15 I 2 I T DE El NS Cl ES
5 n ”
out of 72 done for prosthetic reasons, which represents 8.8% and 5.5%, respectively. This difference was not statistically significant. In the therapeutic group, the incidence of alveolar osteitis was 82 of 341 extractions done because of infection, and 19 of 93 extractions done because of caries, which represents 26.1% and 20.4%, respectively. Again, the difference was not statistically significant. The number of impacted third molars extracted in the lower jaw was 363, and 279 in the upper jaw, which represents 56.5% and 43.5%, respectively, of the total number of extractions. In 20.6% of the patients, two impacted teeth were removed from the lower jaw and, in 18% of the sample, two impacted teeth were removed from the upper jaw. There was no significant difference in the distribution of double impactions between upper and lower jaws. This finding eliminated any bias which might be created by the site of the impaction in those patients who required the removal of two impacted teeth. In the lower jaw, 77 instances of alveolar osteitis occurred, which represents an incidence of 21.2%. In the upper jaw, 37 instances of alveolar osteitis occurred, which represents an incidence of 13.3%. The difference was statistically significant (P < .05). The ratio was 1.6 to 1. The percentage distribution of alveolar osteitis following both prophylactically and therapeutically indicated extractions in the upper and lower jaws are shown in Table 1. Considering each jaw separately, the difference in the incidence of alveolar osteitis between the prophylactic and therapeutic groups was statistically significant (P < .Ol). In the prophylactic group, there was no significant difference in the incidence of alveolar osteitis between
the upper and the lower jaw, whereas the difference was statistically significant in the therapeutic group (P < .05). The incidence of alveolar osteitis was 18.1% in male and 16.9% in female patients. The difference is not statistically significant, at P < .005 (N = 642, df = I.$ = 0.1170). Of the 129 female patients included in this study, only 17 (13.2%) were receiving contraceptive pills at the time of the operation. The total number of impacted teeth removed in the females receiving contraceptive pills was 17, and all extractions were indicated for therapeutic reasons. Of the 17. 4 patients (23.5%) subsequently developed alveolar osteitis. All of the extractions were in the lower jaw. The percentage distribution of incidence of alveolar osteitis in the different age groups is shown in Figure 3. The alveolar osteitis incidence increased with age, peaking in the 31- to 35-year age group. This tinding was statistically significant (P < .005). Table 1. The Percentage Distribution of Alveolar Osteitis Following the ExtractIon of 279 Upper Imp8cted Wisdom Teeth and 383 Lower Impacted Wisdom Teeth Prophylactic
Alveolar osteitis Normal healing
For the upper teeth, N = 219. df = 1, P < ,005, x2 = 8.1434. For the lower teeth, N = 363. df = 1. P < 405. x2 = 8.9334.
Discussion Alveolar osteitis is a clinical complication of considerable importance. Its prevention would benefit both patient and profession alike. Several scientific studies have been carried out to determine means by which alveolar osteitis might be prevented. For example, Hall et al9 evaluated the merits of the local application of tetracycline, and Goldman et al” evaluated the benefits of the local application of Lincomycin (Upjohn, Kalamazoo, MI) on gelfoam. Gersel-Pedersen” applied tranexamic acid to the alveolar socket, and MacGregor and Addyi2 evaluated the value of penicillin in the prevention of complications following removal of ectopic third molars. More recently, Julius et alI3 attempted to prevent alveolar osteitis by local application of Terra-cortril (Pfizer Laboratories, New York, NY) in gelfoam. All of these studies, and innumerable others, have been designed to find a pharmacologic formula to prevent alveolar osteitis. A quite different approach to the prevention of alveolar osteitis has been proposed by Tjernberg,14 who investigated the effect of plaque control and oral hygiene on the incidence following the surgical removal of mandibular third molars. He concluded that preoperative plaque control and good oral hygiene may be a possible way to decrease the incidence of alveolar osteitis. More recently, it has been suggested by McMillanlS that one of the causative factors of alveolar osteitis is a fibrinolytic mechanism that results in the breakdown of the blood clot in the socket. Bim16 showed that tibrinolysis did occur in alveolar osteitis and that its level was directly proportional to the severity of the preoperative symptoms. According to Birn’s hypothesis, a reduction in the incidence of alveolar osteitis could be anticipated in the absence of preoperative symptoms.
I T DE El NS Cl ES
The findings of this study, which show that the lowest incidence of alveolar osteitis was recorded in patients in the prophylactic group, that is, with no preoperative signs or symptoms of inflammation, would seem to agree with the conclusions of these three authors. 14-i6 In this study, the incidence of alveolar osteitis in the lower jaw was significantly higher than that in the upper jaw (Table 1). Comparing the incidence of alveolar osteitis between the different indications in each jaw separately, the findings show that the incidence was significantly higher following therapeutic extractions in both jaws. In this study there also was no significant difference in the incidence of alveolar osteitis between male (18.1%) and female (16.9%) patients, with a ratio of 1 to 1.1. This finding is in disagreement with that of MacGregor, l9 who not only reported that the female complained of more postextraction pain than the male, but that the alveolar osteitis ratio between males and females was 2 to 3. MacGregor’s figures, however, were garnished from a population of patients who had extractions under local anesthesia and alveolar osteitis was diagnosed only when a patient returned with appropriate signs and symptoms. Not all of the patients were seen postoperatively, so it was possible that others with pain had not returned. While several other studies support MacGregor’s findings, it is notable that most, if not all, were based on a retrospective evaluation of patient records rather than on a study specifically designed to test various hypotheses. On the other hand, the studies of Gersel-Pederson, l1 Catellani,” and Nordenrain and Grave” on the relationship between oral contraceptives and menstruation and the incidence of alveolar osteitis in women are relevant. Although the number of females in this study who were on contraceptive drugs was extremely small, and all required extraction for therapeutic reasons, the finding that 4 of 17 (23.5%) subsequently presented with alveolar osteitis lends support, albeit tenuous, to the claim made by several investigators1’-19 that the use of oral contraceptives produces a significant increase in the incidence of alveolar osteitis. The results of this study also show that the incidence of alveolar osteitis is not age-dependent, as MacGregor6 and others have claimed. On the other hand, the peak incidence of alveolar osteitis was in the years 31 to 35, which is in agreement with MacGregor,6 who reported a peak incidence in the 30- to 34-year age group. Conclusion
AGE GROUP (In years)
FIGURE 3. Percentage distribution of alveolar osteitis in different age groups.
In this study, the incidence of alveolar osteitis following the removal of 642 impacted third molars
ALEC J. MACGREGOR
in a sample of 412 patients was found to be 17.8%. This incidence is higher than that reported by most authors in other countries, with whom the range was from 5% to 10%. The results show that the incidence was much higher (21.9%) when the impacted third molars were removed for therapeutic rather than prophylactic reasons (7.1%). This statistically significant difference in the incidence of alveolar osteitis seems, therefore, to be the result of the late removal of the impacted teeth when infection, such as chronic pericoronitis, had already become established. These findings indicate that the incidence of alveolar osteitis could be reduced significantly by the early removal of impacted teeth as a prophylactic measure, that is, prior to their eruption and the development of chronic inflammation of the pericoronal tissues. Many patients, however, are unwilling to agree to the removal of their impacted wisdom teeth for prophylactic reasons, choosing instead removal only if there is a tangible complaint related to the impaction. This observation is supported by one of the findings of this study that shows that the difference between the number of prophylactic extractions (28.3%) and therapeutic extractions (71.7%) was statistically significant. The ratio was 1 to 2.5. If the findings of this controlled study can be used as a yardstick, however, then patients should be made to realize that the possibility of their developing alveolar osteitis following the removal of impacted teeth is much greater if the removal is delayed until the tooth partly erupts and develops pericoronal inflammation. References I. Belinfante LS. Marlow CD, Meyers W, et al: Incidence of dry socket complication Surg 31:106. 1973
J Oral Maxlllofac 49:145-146.
in third molar removal. J Oral
2. Keskitalo E, Persson G: Complication after removal of mandibular third molars with special reference to local anaesthetics with different vasoactive properties. Odont Rev 26: 149, 1975 3. Swanson AE: Reducing the incidence of dry socket: A clinical appraisal. J Can Dent Assoc 32:25, 1966 4. Erickson RI, Waite DE, Wilkinson RH: A study of dry sockets. Oral Surg Oral Med Oral Path01 13: 1046, 1960 5. Bim H: Etiology and pathogenesis of fibrinolytic alveolitis (drv socket). Int J Oral Surr! 2:21 I. 1973 6. MacGregor AJ: Aetiology of dry sockets: A clinical investigation. Br J Oral Surg 6:49, I%8 7. Lehner T: Analysis of one hundred cases of dry socket. Dent Pratt 8:275. 1958 8. Krekmanov L, Hallander HO: Relationship between bacterial contamination and alveolitis after third molar surgery. Oral Surg Oral Med Oral Pathol 9:274. 1980 9. Hall HD, Bildman BS. Hand CD: Prevention of dry socket with local application of tetracycline. J Oral Surg 29:35, 1971 10. Goldman DR, Kilgore DS, Panzer ID. et al: Prevention of drv socket bv local aoolication of Lincomvcin + in gelfoam. Oral Surg 3;:472, 19?i II. Gersel-Pedersen N: Tranexamic acid in alveolar sockets in the prevention of alveolitis sicca dolorosa. Int J Oral Surg 8:42 1, 1979 12. MacGregor AJ, Addy A: Value of penicillin in the prevention of pain, swelling and trismus following the removal of ectopic mandibular third molars. Int J Oral Surg 9:166, 1980 13. Julius LL, Hungerford RW, Nelson WJ, et al: Prevention of dry socket with local application of Terra-cortil in gelfoam. J Oral Maxillofac Surg 40:285, 1982 14. Tjemberg A: Influence of oral hygiene measures on the development of alveolitis sicca dolorosa after surgical removal of mandibular third molars. Int J Oral Surg 8:430, 1979 IS. McMillan MD: The healing of oral wounds. N Z Dent J 82:112. 1986 16. Birn H: Fibrinolytic activity of alveolar bone in “dry socket.” Acta Odont Stand 30:23, 1972 17. Catellani JE: Review factors contributing to dry socket through enhanced fibrinalysis. J Oral Surg 37:42, 1979 18. Nordenram A and Grave S: Alveolitis sicca dolorosa after removal of impacted mandibular third molars. Int J Oral Surg 12:226, 1983 19. Catellani JE. Harvey S, Ericson SH, et al: Effect of oral contraceptive cycle on dry socket (Localized alveolar osteitis). J Am Dent Assoc 101:777, 1980
Discussion The Relationship Between the Indications for the Surgical Removal of Impacted Third Molars and the Incidence of Alveolar Osteitis Alec J. MacGregor The Unit~ersify of Leeds, England
Alveolar osteitis, also known as dry socket, is a painful condition that may occur after the extraction of a tooth.
Researchers in this field have two problems. First, the condition has an overall incidence of less than 5%, and it borders on the impractical to generate large enough groups to make meaningful studies. Secondly, it is not normal practice to review all patients who have had simple extractions; therefore, the incidence of dry socket as determined in a noncaptive population may reflect only a propensity to complain of pain. It is this explanation, for example, and not the contraceptive pill, that most likely accounts for the higher incidence among females. Fibrinolysis may well be involved in the pathologic mechanism