Oral Surgery

25. When to extract

When is the ideal timing of first permanent molar extraction to reduce the future need for orthodontic treatment? A computerised database and subsequent manual search was performed. Extractions at the age of 8-10.5 years tended to show better spontaneous clinical outcomes compared to the other age groups. By pooling the data from mandibular sites, extractions performed at the age of 8-10.5 and 10.5-11.5 years showed significantly superior spontaneous clinical outcome with a probability of 50% and 59% likelihood, respectively, to achieve good to perfect clinical result compared to the other age groups (<8 years of age: 34%, >11.5 years of age: 44%). The overall success rate of spontaneous clinical outcome for maxillary extraction of first permanent molars was superior to mandibular extraction. Extractions of mandibular first permanent molars should be performed between 8 and 11.5 years of age in order to achieve a good spontaneous clinical outcome. For the extraction in the maxilla, no firm conclusions concerning the ideal extraction timing could be drawn.

Eichenberger M et al. The timing of extraction of non-restorable first permanent molars: a systematic review. European J Paediatric Dent 2016 16: 272-278.

Q The ideal timing for extraction of non-restorable first permanent molars is:
A Best performed between 8 and 11.5 years
B Better done only in the mandible
C Calculated to be best after the age of 11.5 years
D Should be avoided at all costs

26. Rinsing before extraction

A total of 201 patients who underwent a tooth extraction were randomly distributed into four groups: 52 received no prophylaxis (control), 50 used a mouthwash with 0.2% chlorhexidine (CHX) before the tooth extraction, 51 a mouthwash with 0.2% CHX and a subgingival irrigation with 1% CHX and 48 a mouthwash with 0.2% CHX and a continuous supragingival irrigation with 1% CHX. Peripheral venous blood samples were collected at baseline, 30 seconds after using the mouthwash and the subgingival or supragingival irrigation, and at 30 seconds and 15 minutes after completion of the tooth extraction. Streptococci (mostly viridans group streptococci) were the most frequently identified bacteria (69-79%). Performing a 0.2% CHX mouthwash significantly reduces the duration of PEB. Subgingival irrigation with 1% CHX did not increase the efficacy of the mouthwash while supragingival irrigation even decreased this efficacy, probably due to the influence of these manoeuvers on the onset of bacteraemia. These results confirm the suitability of performing a mouthwash with 0.2% CHX before tooth extractions.

Barbosa M et al. Post-tooth extraction bacteraemia: a randomized clinical trial on the efficacy of chlorhexidine prophylaxis. PLoS ONE [Electronic Resource] 2015 10: e0124249.

Q What significantly reduced the bacteraemia subsequent to tooth extraction?
A A subgingival irrigation with 1% CHX
B Taking a peripheral venous blood sample
C Rinsing with salt water
D Performing a 0.2% CHX mouthwash

27. Paracetamol and ibuprofen

Combined paracetamol and ibuprofen has been shown to be more effective than either constituent alone for acute pain in adults, but the dose-response has not been confirmed. The aim of this study was to define the analgesic dose-response relationship of different potential doses of a fixed dose combination containing paracetamol and ibuprofen after third molar surgery. Patients aged 16-60 years with moderate or severe pain after the removal of at least two impacted third molars were randomised to receive double-blind study medication as two tablets every 6 h for 24 h of either of the following: two tablet, combination full dose (paracetamol 1,000 mg and ibuprofen 300 mg); one tablet, combination half dose (paracetamol 500 mg and ibuprofen 150 mg); half a tablet, combination quarter dose (paracetamol 250 mg and ibuprofen 75 mg); or placebo. All doses of the combination provide safe superior pain relief to placebo in adult patients following third molar removal surgery.

Atkinson HC et al. Combination paracetamol and ibuprofen for pain relief after oral surgery: a dose ranging study. European J Clin Pharmacol 2015 71: 579-587.

Q Which of the following doses was NOT tested in this research?
A Paracetamol 300 mg and ibuprofen 1,000 mg
B Paracetamol 1,000 mg and ibuprofen 300 mg
C Paracetamol 250 mg and ibuprofen 75 mg
D Placebo, as it would be unethical

28. Education is key

The authors hypothesised that an audiovisual presentation of treatment information on the removal of an impacted mandibular third molar could improve patient knowledge of postoperative complications and decrease anxiety in young adults before and after surgery. A group that received this was compared with another that received the conventional written description of the procedure. The outcome variables were the State-Trait Anxiety Inventory, the Dental Anxiety Scale, a self-reported anxiety questionnaire, completed immediately before and 1 week after surgery, and a postoperative questionnaire about the level of understanding of potential postoperative complications. The audiovisual group remembered significantly more information than the control group about a potential allergic reaction to local anaesthesia or medication and potential trismus. The audiovisual group had lower self-reported anxiety scores than the control group 1 week after surgery. These results suggested that informing patients using an audiovisual presentation could improve their knowledge about postoperative complications and aid in alleviating anxiety after the surgical removal of an impacted mandibular third molar.

Choi SH et al. Effect of audiovisual treatment information on relieving anxiety in patients undergoing impacted mandibular third molar removal. J Oral Maxillofacial Surg 2015 73: 2087-2092.

Q Using an audiovisual presentation about third molar surgery prior to the procedure:
A Was counterproductive as it made patients more anxious
B Increased patient knowledge but did not reduce anxiety
C Improved knowledge and reduced anxiety
D Took too much time and the expense outweighed any advantage