Third molar treatment outcome: a comparison of patients' preferences in Sweden and Wales.

AIM: To elucidate and compare patients' outcome preferences for removal and retention of mandibular third molars in Sweden and Wales. SUBJECTS AND METHOD: The subjects comprised patients referred and scheduled for removal of one or both mandibular third molars in Sweden and Wales. The multi-attribute utility (MAU) methodology was applied to study patients' preferences for outcomes of removal and retention of the mandibular third molar. RESULTS: Relative weighting of domains was similar in the two countries. "Home and social life" received the highest relative weighting in Sweden and "general health and wellbeing" in Wales. "Your appearance" received the lowest relative weighting in both countries. In both Sweden and Wales operative jaw fracture was considered to be the outcome with most impact, and dentigerous cyst and imbricated incisors the least impact. Outcome ranking was similar in both countries and operative outcomes were considered by patients to be more detrimental to health than retention outcomes. CONCLUSIONS: This comparison showed that patients' preferences in Sweden and Wales were similar and that the outcomes of surgery were considered worse after third molar removal than retention. Patient-orientated treatment decisions were less subject to variation than clinician-orientated decisions.

Dentists' decisions on prophylactic removal of mandibular third molars: a 10-year follow-up study.

OBJECTIVES: In recent years, several critical outcome studies concerning the prophylactic removal of mandibular third molars have been published. These would appear to motivate a more restrictive approach today as compared with 10 years ago. The aim of the present study was to examine dentists' decisions on the prophylactic removal of impacted mandibular third molars over a 10-year period. METHODS: Thirty-six cases were selected so as to represent an equal distribution of males and females, ages, angular position and degree of impaction of the molar. Twenty-six general dental practitioners (GDPs) and 10 oral surgeons judged the same cases on two occasions 10 years apart. RESULTS: Calculated for each category of dentists, there was no significant difference in the mean number of molars designated for removal between the two occasions. Two GDPs and three oral surgeons presented a higher removal rate, whereas five GDPs presented a lower removal rate on the second occasion as compared to the first one. The dentists presented a considerable interindividual variation in removal rate, between 0 and 22 molars on the first occasion and between 0 and 25 molars on the second occasion. CONCLUSION: In the decisions on prophylactic removal of mandibular third molars, there has been no change over the last 10 years towards a more noninterventionist attitude. Thus, the dentists seem not to have been influenced by the evidence that this intervention is not cost-effective.

Comparison of decisions regarding prophylactic removal of mandibular third molars in Sweden and Wales.

OBJECTIVE: To test the hypothesis that Swedish dentists schedule more mandibular third molars for prophylactic removal compared with UK dentists and oral surgeons. DESIGN: Clinical and radiographic information relating to a stratified sample of 36 disease-free mandibular third molars (equal distribution of males and females, patients' age, angular position and degree of impaction) was presented to 26 general dental practitioners (GDPs) and 10 oral surgeons in Sweden and 18 GDPs and 10 oral surgeons in Wales who were asked to decide whether or not the third molars should be removed. RESULTS: There was no evidence of any difference in mean number of molars scheduled for removal by the GDPs, but the Swedish oral surgeons scheduled significantly more third molars for removal than oral surgeons in Wales. CONCLUSION: The less interventionist approach among oral surgeons in the UK may reflect the development and application of authoritative guidelines in the UK and an extensive debate concerning appropriateness of prophylactic removal there.

The outcomes of mandibular third molar removal and non-removal: a study of patients' preferences using a multi-attribute method.

The aim was to study patients' preferences about outcomes of mandibular third molar removal and non-removal using multi-attribute utility (MAU) methodology. The study comprised three stages. Stage 1: Elicitation of domains, i.e. main areas of patients' lives which could be affected by third molar removal and non-removal. Stage 2a: Interdomain weighting was obtained by relative weighting of the domains elicited in Stage 1. Stage 2b: Intradomain weighting obtained by patients' designation of values for different health states of each domain. Stage 3: Rating of outcomes. The patients were asked to imagine experiencing a variety of outcomes of mandibular third molar removal and non-removal, described in 19 short vignettes. The numbers of patients interviewed for the three stages were 30, 78, and 55, respectively. Five domains were identified. The mean relative weightings were approximately equal for the domains "Home and social life" and "General health and well-being", followed in order of importance by 'Job and studies" and "Health and comfort of mouth, teeth and gums". "Your appearance" received the lowest mean relative weighting. The vignette, which described the presence of a fluid-filled sac and suggested that this tooth must be removed, received the highest mean preference (least effect on patients' lives). The lowest mean preference (most effect on patients' lives) was generated by the vignette, which stated that the jaw was broken and that the teeth must be wired together for 6 weeks. We conclude that, from the patient's perspective, outcomes of non-removal were preferable to outcomes of mandibular third molar removal.

Dentists' judgment strategies on prophylactic removal of mandibular third molars.

The number of molars selected for prophylactic removal varies widely among general dental practitioners and oral surgeons. To understand the basis for such variations, we investigated two hypotheses: (1) Individual judgment strategies will differ concerning the use of cues (items of information), and (2) few dentists will integrate the cues according to evidence in the literature. To analyze 30 general dental practitioners' (GDPs) and 10 oral surgeons' use of cues in the judgment preceding the treatment decision, we used the Brunwik's lens as a conceptual model. The cues were the patient's age, and the angular position and the degree of impaction of the molar. The clinical situation was simulated by written case descriptions. The proportion of variation explained by the cues and their combinations (total model) varied between 61% and 100% and between 4% and 76% as main effects. Two GDPs and one oral surgeon integrated the cues additively, i.e., any of the cues is independent of the other cues in the judgment. In general, the dentists integrated the cues interactively, i.e., the impact of one cue depends on the levels of some other cues. Even though most variations in judgments were accounted for by the cues, the dentists did not integrate the cues according to evidence in the literature and lacked insight into their decision-making thought processes.

Mandibular third molars: oral surgeons' assessment of the indications for removal.

The aim was to examine oral surgeons' assessment of the indications for removal of mandibular third molars. Questionnaires were distributed to seven oral and maxillofacial surgery clinics. The oral surgeons were asked to record whether or not there was associated disease. Three other factors were recorded: patient's age, and angular position and extent of eruption of the molars. The strength of the indication for removal was rated on a visual analogue scale (VAS) where 0= weakest and 100= strongest indication for removal. The results were based on data from 666 molars: 118 (18%) had no disease, 465 (70%) had one associated disease, 77 (11%) had two and 6 (1%) had three. The indication for removal as expressed by the mean VAS for molars with no disease was assessed to be weaker (P<0.05) than that for molars with one, two, or three diseases. The only factor that influenced the indication for removal in molars with no disease was the patient's age.

Mandibular third molars as mediated by three cues. Dentists' treatment decisions on asymptomatic molars compared with molars associated with pathologic conditions.

The aim was to study how three cues (patient's age and angular position and degree of impaction of the molar) were distributed among removed mandibular third molars associated with pathologic conditions and to compare these results with dentists' treatment decisions in another group of molars consisting of asymptomatic mandibular third molars, as mediated by the same cues. The overall agreement was fairly high between the dentists' treatment decisions and the removal rate among the molars subjected to removal. Thus, molars partially covered by soft tissue in patients aged 19 to 40 years had a high removal rate, and molars totally covered by bone tissue had the lowest removal rate in accordance with the dentists' treatment decisions. There were some exceptions. For example, molars partially covered by soft tissue in horizontal and mesioangular positions were rated higher by the dentists than the removal rates indicated. Distoangular molars in patients aged 26 to 40 years had the highest removal rate but a considerably lower order according to the dentists' decisions. Scientific evidence indicates that molars in mesioangular and horizontal positions present a low risk and molars in distoangular position present the highest risk of developing pathologic conditions, compared with other angular positions.

Judgement of removal of asymptomatic mandibular third molars: influence of position, degree of impaction, and patient's age.

Our aim was to study general dental practitioners' (GDPs') and oral surgeons' judgement of the need for removal of asymptomatic mandibular third molars, described by three cues. The judges were also asked to estimate the development of pathologic conditions. There was considerable variance with regard to the individual judgements. As a group, GDPs estimated the need for removal to be higher for patients less than 40 years than those more than 40 years old. The oral surgeons estimated the need to differ for three different age groups. The GDPs estimated the need to be highest for distoangular molars and lowest for vertical molars, whereas the oral surgeons estimated these positions to be equal. Molars partially covered by soft tissue were given the highest priority for removal by both groups of judges. The mean proportion of variation explained by the three cues was high, except for tumor development, indicating that the judges used the cues and the combination of them to a great extent in their judgement of the risk for development of pathologic conditions.

Pathoses associated with mandibular third molars subjected to removal.

OBJECTIVES: To measure the prevalence of disease of mandibular third molars referred for removal and to estimate the risk for development of pathoses for two cues. STUDY DESIGN: A prospective cohort study on molars subjected to removal was performed. The prevalence of different diseases and the patient's age, angular position, and degree of impaction of the molars were registered. Odds ratio for molars with different positions and impaction states were estimated. RESULTS: Pericoronitis was found in 64% of cases, caries in the third molar in 31%, periodontitis in association with 8%, caries in the second molar in 5%, and root resorption of the second molar with 1% of the molars with pathoses. Odds ratio was highest for distoangular molars (5.8) and for molars partially covered by soft tissue (6.7). CONCLUSIONS: The odds ratio is about 22 and 34 times higher for molars partially covered by soft tissue than for molars completely covered by soft or bone tissue. For distoangular molars the odds ratio is 5 to 12 times higher than for molars in other positions.

Rating the preventive indication for mandibular third-molar surgery. The appropriateness of the visual analogue scale.

The aim was to determine whether a visual analogue scale (VAS) is an appropriate way for general dental practitioners and oral surgeons to rate their judgement of the indication for therapy of asymptomatic mandibular third molars. Thirty general dental practitioners and 10 oral surgeons had to judge the need for removal of 36 third molars. They were also asked to estimate the strength of the indication for extraction on a VAS. To assess the reliability of the judgment, the 36 cases were duplicated. For each participant, two mean indication indices with 95% confidence limits were calculated, one index for molars proposed to be extracted and one index for molars proposed not to be extracted. Pearson's correlation coefficient was used to estimate the intra-examiner reliability and the correlation between the number of molars proposed for extraction and the mean indication index. The correlation between the number of molars proposed to be extracted and the mean indication index was high (p < 0.001). The intra-examiner reliability was also high, with a mean correlation coefficient of 0.72 for the general practitioners and 0.84 for the oral surgeons. No single judge presented any overlap for the 95% confidence limits for the mean indication index of teeth proposed to be extracted versus teeth proposed not to be extracted. These results indicate that the VAS seems to be an appropriate method for analyzing the judgements on a therapeutic strategy like extraction versus no intervention for asymptomatic mandibular third molars.

Judgement on removal of asymptomatic mandibular third molars: influence of the perceived likelihood of pathology.

Thirty general dental practitioners and 10 oral surgeons were asked to judge the need for removal of 36 asymptomatic impacted third molars. To estimate the reliability of the judgement, the 36 cases were duplicated. The participants had to estimate the strength of the indication for extraction and, if the teeth were not extracted, the probability of development of pathology in general and of six specific complications on a Visual Analogue Scale. Multiple linear regression analysis was used to describe their judgement. There was a high correlation between the indication index for extraction and the perceived likelihood of the development of pathology, although there was considerable individual variation. The general dental practitioners rated cyst development as the most, and pericoronitis as the second most, influential factors in their decision to extract the third molar. The oral surgeons rated pericoronitis the highest and the development of a cyst or caries in the second molar as the second highest factors influencing their judgement. Tumour formation and root resorption received low weightings. Intraexaminer reliability was high. The study confirms that the judgement to extract asymptomatic impacted third molars is not made solely on the basis of cognitive factors.

General dental practitioners' evaluation of the need for extraction of asymptomatic mandibular third molars.

Thirty general dental practitioners were asked to evaluate the need for extraction of asymptomatic mandibular third molars. Thirty-six mandibular third molars with equal distribution of angular positions, impaction status, males and females and age groups were selected. To estimate the consistency of the evaluation, the 36 cases were duplicated so that, in all, 72 teeth were evaluated. The number of molars proposed to be extracted by the observers varied from 0 to 26. There was no third molar which all observers agreed should be extracted. The two molars which most observers, 25 and 23 of altogether 30 observers, proposed to be extracted were partially covered by soft tissue. The decision not to extract two molars was unanimous. Both of these were completely covered by bone tissue and positioned vertically. The mean overall intra-observer agreement for the therapeutical decision was 92%, with a range of 69-100%. The length of professional experience of the observer did not influence the evaluation whether or not to extract. We conclude that there is a great variation among general dental practitioners regarding their evaluation on the need for removal of asymptomatic mandibular third molars.

Asymptomatic mandibular third molars: oral surgeons' judgment of the need for extraction.

Ten oral surgeons were asked to judge the need for extraction of asymptomatic mandibular third molars. Thirty-six mandibular third molars with equal distribution of angular position, impaction status, and patient's sex and age were selected. To estimate the consistency of judgment, the 36 cases were duplicated so that, in all, 72 cases were judged. The judgment of the oral surgeons was compared with that of 30 general dental practitioners (GDPs). The number of mandibular third molars the oral surgeons proposed to extract varied from 3 to 21 of 36 teeth. The mean number of molars proposed for extraction was 12 for the oral surgeons and 13 for the GDPs. There was no third molar that all the observers in the two groups agreed should be extracted. About three times as many observers in both groups proposed extraction of molars partially covered by soft tissue. The oral surgeons were unanimous in their judgment not to extract 11 molars, and the GDPs were also unanimous in judgment not to extract two of these. The mean intraobserver agreement within the two groups was comparable, 94% for the oral surgeons and 92% for the GDPs. We conclude that there is a great variation among oral surgeons in their judgment on the need for removal of asymptomatic mandibular third molars. A similar variation in judgment also was observed among GDPs.

Pain control after third molar surgery--a comparative study of ibuprofen (Ibumetin) and a paracetamol/codeine combination (Citodon).

Two analgesics commonly used in oral surgery, ibuprofen (Ibumetin) and a paracetamol/codeine combination (Citodon) have been compared in a single-blind multi-centre trial after third molar surgery. The study comprised 120 patients, 60 in each treatment group. The profiles of postoperative pain in the two groups were similar from the first postoperative day, but Ibumetin was better pain reliever on the day of surgery. The profiles of postoperative swelling and trismus had the same general course, but patients taking Ibumetin reported lower scores for these variables during the whole postoperative period. Citodon induced significantly more side-effects than Ibumetin.

Postoperative status after partial removal of the mandibular third molar.

The aim of the study was to examine the postoperative status one year after partial removal of the third mandibular molar. Thirty-three third molars were selected because of the proximity of the apices to the mandibular canal and/or complicated root anatomy. At a follow-up examination one year postoperatively, clinical and radiological findings were recorded. A definition based on both clinical and radiological findings for healing and unsatisfactory healing, respectively, is suggested. Twenty-seven root fragments migrated between 1 and 7 mm coronally in the length axis of the tooth. Nine patients had subjective symptoms or objective findings. Three of these patients had dysesthesia. The findings indicated healing around 24 root fragments (73%) and unsatisfactory healing around 9 root fragments (27%). This findings of healing around most of the root fragments indicates that partial removal might be considered as an alternative method in certain cases of complicated root anatomy.

Prevalence of impacted third molars in dental students.

To study the prevalence of third molar impaction in dental students, the radiographs of 113 female and 144 male students in the age groups 20-39 years were investigated. Half of the individuals had all four third molars, whereas 10% of the individuals lacked all third molars. A radiologic definition of impaction, which is illustrated, is suggested. One or more impacted third molars were found in 33% of the individuals. The difference between the sexes regarding impacted third molars was not significant. Calculated by number of teeth, one fourth of all third molars were impacted and were then mostly in a vertical or mesioangular position. The frequency of impacted third molars was higher in the lower jaw compared to the upper jaw.

A study of indications used for removal of the mandibular third molar.

To study the indications used for removal of the mandibular third molar, questionnaires were sent to 35 Oral Surgery Clinics in Sweden, out of which 29 clinics participated. In each clinic, the questionnaires were to be recorded for 30 patients. The indications for removal were classified into 15 groups. There were also questions about symptoms as well as eruption status for the molar being removed. The results were based on data from 870 individuals with a mean age of 27 years. More than half of the removed third molars (54%) presented no subjective symptoms. Such symptoms were more frequent in association with fully or partially erupted molars than molars completely covered by soft or bone tissue. The indication for removal was classified as prophylactic in 27% and as orthodontic in 14%. Earlier episodes of pericoronitis consisted of 1/4 of the indications and caries or pulpitis of the third molar made up 13%. Pathologic entities like cysts, tumours and root resorption were registered in less than 3% each, and were more frequent among patients 40 years of age or older.

Initial Tc-99m diphosphonate uptake in mineralized and demineralized bone implants in rats.

Radionuclide imaging has been suggested as a means to assess healing and viability of bone grafts and implants. This study deals with the in vivo uptake of 99mTc-MDP in the initial postoperative period in rats. Isogeneic or xenogeneic bone was implanted in subcutaneous pouches. The isogeneic grafts and implants were treated with saline or freeze-treated or demineralized. The xenogeneic implants consisted of Kiel bone or collagen sponge. One day after surgery, the accumulation of 99mTc after an intraperitoneal injection of 99mTc-MDP was seen in all grafts and implants containing bone mineral independent of prior treatment of the graft and implant. In implants composed of only the organic part of bone, no accumulation was observed. One prerequisite for accumulation of 99mTc-MDP is the presence of the inorganic phase. Thus, the interpretation of the initial postoperative scan is based on whether or not the graft or implant initially contained mineral.