Cohort study of pain symptoms and management following impacted mandibular third molar extraction

Factors affecting number of third molars extracted in a single visit

OBJECTIVE

This cross-sectional study evaluated the number and characteristics of third molars extracted in a single visit in primary care and their associations with patient's age and sex and operator's experience.

MATERIALS AND METHODS

The data included all appointments where routine and surgical extractions of third molars were performed in 2016 in primary care of the City of Helsinki. Statistics included χ2 and Mann-Whitney U tests, and binomial logistic regression.

RESULTS

In total of 10,894 appointments, the number of extracted third molars was 12,728, yielding an average of 1.2 third molars per visit. Mean age of patients (55% women, 45% men) at extraction was 32.2 years (range 12 - 97 years). Most appointments (83.7%, n = 9,118) comprised extraction of one, 15.8% two, 0.4% three, and 0.1% four third molars. Number of teeth extracted at a time did not differ by sex. Increasing age was associated with a reduction in the likelihood of several third molar extractions in a visit (OR 0.96; 95% confidence interval (CI) 0.96-0.97). Multiple third molars were extracted significantly more likely if the operator was experienced (OR 2.32; 95%CI 1.90-2.84). Multiple extractions were also associated with the mandible, operative extractions, unerupted teeth and caries.

CONCLUSIONS

Third molars were typically extracted one at a time. In health care units, it is appropriate to consider extraction of several third molars in a single visit, if need for extraction of other third molars exist. Concentrating the extractions of younger patients on experienced operators would reduce the number of patients' visits.

Mouth-Opener Technique for Ultrasound-Guided Inferior Alveolar Nerve Block: A Case Series of Extraction of Impacted Mandibular Third Molars

Extraction of the impacted mandibular third molar (IMTM) is common in oral surgery, but its postoperative pain is severe. Ultrasound-guided inferior alveolar nerve block (UGIANB) is an analgesic technique in the mandibular nerve region. We describe UGIANB using a mouth opener and report the cases with a good postoperative course. Six patients underwent the extraction of bilateral IMTMs under general anesthesia. After surgery, we performed UGIANB and administered 5 mL of 0.375% levobupivacaine on each side. The postoperative numerical rating scale pain scores were 1 (0-2) and 2.5 (0-5) (mean (range)), postoperative day one and seven, respectively. The postoperative quality of recovery-40 scores were 188.5 (8.1) and 191.7 (7.6) (mean (SD)), postoperative day one and seven, respectively. No procedural complications were encountered. We performed UGIANB with a mouth opener on a patient with IMTM extraction and were able to provide safe and good analgesia.

Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials

BACKGROUND

Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050).

FINDINGS

47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes.

INTERPRETATION

Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field.

FUNDING

The Canadian Institutes of Health Research.

Effects of Low-Level Laser Therapy on Osseous Defects Distal to Mandibular Second Molar after Extraction of Impacted Third Molar

Objective

To evaluate the efficiency of low-level laser therapy on the distal osseous defects of the mandibular second molar (M2) after the adjacent impacted third molar (M3) extraction.

Methods

A total of 59 clinic cases were screened out, whose M3 were impacted and the distal alveolar bone of M2 had been destroyed horizontally. They were randomly divided into 2 groups based on whether they would have laser irradiation or not after M3 extraction. Then, postoperative complications of the 2 groups were compared. The alveolar bone level distal to M2 was established before and 3 to 6 months after M3 extraction by radiographic evaluation, which was compared between two groups.

Results

The incidence of severe pain and mouth-opening limitation was significantly lower in the LLLT group than that in the control group. The amount of bone formation in the LLLT group was higher than that in the control group 3 months after the operation, and the difference was statistically significant. But the difference was not statistically significant 6 months after surgery.

Conclusion

LLLT may alleviate postoperative complications and improve early osteogenesis. It is a viable option for use in the treatment of osseous defects distal to mandibular second molars following extraction of impacted third molars.

Piezo-surgery technique and intramuscular dexamethasone injection to reduce postoperative pain after impacted mandibular third molar surgery: a randomized clinical trial

Background

Surgical extraction of the impacted mandibular third molar is commonly associated with postoperative pain, swelling, and trismus. Usually, rotatory instruments like burs have been used for osteotomy, while Piezosurgery is an innovative technique introduced to overcome the weaknesses related to the conventional technique. In addition, Dexamethasone administration before the extraction of impacted third molars is an efficient way to reduce postoperative pain due to robust anti-inflammatory activity. The purpose of the study is to evaluate the effect of piezo-surgery and dexamethasone injection on postoperative sequelae after the surgical extraction of impacted mandibular third molars, and ultimately to compare their effect on reducing postoperative pain.

Methods

A randomized controlled clinical trial was conducted with a sample of 80 patients. Participants were divided into four groups: Group 1 (Conventional rotatory), Group 2 (Conventional rotatory with 8 mg dose of dexamethasone 30 min before surgery), Group 3 (Piezo-surgery), and Group 4 (Piezo-surgery with 8 mg dose of dexamethasone 30 min before surgery). The outcome variables were surgical working time calculated in minutes, maximal mouth opening measured in millimeters using Vernier Caliper at baseline and day 3 and postoperative pain assessed using a Visual Analog Scale (VAS) on days 1, 3, and 7.

Results

The surgical working time was longer in piezo-surgery groups compared with the conventional rotatory instruments groups (15.82 ± 3.47 vs 23.33 ± 2.54; p value < 0.0001). The lowest reduction in mouth opening between baseline and 3rd-day post-op was found in the Piezo-surgery with Dexamethasone group (mean difference = 5.0, SD = 3.9, p value < 0.0001) followed by the Piezosurgery without Dexamethasone group (mean difference = 5.8, SD = 4.5, p value < 0.0001) and the highest average was reported by the Conventional rotatory without Dexamethasone (mean difference = 9.7, SD = 4.5, p value < 0.0001. In the four groups, the mean pain score was highest on the 1st day and gradually decreased over the following days. Comparison of the 1st and 3rd postoperative pain between groups revealed a lowest mean pain score in the Piezo-surgery with Dexamethasone group, followed by Conventional rotatory with Dexamethasone group and a highest mean score in the Conventional rotatory without Dexamethasone group (p value < 0.0001).

Conclusion

The association of Piezosurgery osteotomy and Dexamethasone intramuscular injection could be an effective combination to reduce postoperative pain and trismus after impacted third molar surgery.

Trial registration: NCT04889781 (https://clinicaltrials.gov/), Date of Registration: 17/05/2021 (retrospectively registered), https://clinicaltrials.gov/ct2/show/NCT04889781?term=NCT04889781&draw=2&rank=1