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E D I TO R I A L

Outcomes after 3rd molar surgery: what about quality of life?

A recent editorial in our journal considered some of the frequent complications that can arise following removal of 3rd molars1. Attention was drawn to the increasing recognition that patient reported outcome measures (PROMs) can act as an important measure of health-care quality. It would be incorrect to say that quality-of-life issues are only now being addressed, although all too often they are drowned out by tangibles that are only evident to the surgeon when the patient is in the clinic (rather than what happens after they get home). Maybe we made assumptions or made a calculated guess as to what we thought the patient would nd the most disturbing or inconvenient events. How we decide which aspects to mention is a debatable point. Is it the frequency at which something arises? (If so, how frequent? . . . 1 in 10, 1 in 20 or less?). By that token, the paper by Carmichael and McGowan2 showing an incidence of 5% disturbance to the inferior dental (ID) nerve at 1 week (or less than 1% after a year) is often quoted. Yet it is considered mandatory to mention the risk to the ID (and lingual) nerves. So is it a frequency of 1% or less? Perhaps it is not the frequency but rather the permanency of the complication that justies its inclusion in the list of risks to be covered when obtaining consent. Is it what you consider to be the most likely risks pertaining in that particular patient? Common sense suggests that those surgeons with more experience are more likely to have a better handle on the potential complications and effects of surgery, but where is the evidence? Who would have thought that the form of anaesthesia (General Anaesthesia (GA) rather than Local Anaesthesia (LA)) had a greater impact on quality of life than surgical difculty3. Blanket warnings with a catch all clause might serve to help protect us from claims of negligence (You never told me that might happen), but how often do patients recall accurately what they have read or been told? Consent to the removal of 3rd molars (indeed any operation) has moved along way, to the extent that the risk and benets have to be nely judged. Which brings us back to the issue of what risks do we mention? Over 15 years ago, we found that even 1 week after 3rd molar removal, many patients experienced
Oral Surgery 7 (2014) 12. 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

changes in diet and ability to eat, with one in seven patients losing self-condence, one in three disinclined to socialise and one in two requiring up to a week off work4. Indeed, half of all patients still experienced pain despite taking recommended analgesics. Furthermore, to emphasise the effect it had on their life, 20% would not recommend 3rd molar surgery again (hence the reason to be sure the tooth really does require removal). When we asked 121 general dental practitioners (GDPs), all the oral and maxillofacial surgery consultants in Scotland and 120 patients who had had their 3rd molars removed within the last year what the most signicant effect of 3rd molar removal was, those with a dental background ranked pain as the most signicant factor to affect the patient. However patients ranked the effect on ability to eat and enjoy food as the most signicant issue5. Did we think it too obvious to mention? Given its ranked order by the patients, should we not mention it every time we seek consent? After all, its incidence is far greater than 1 in 100. It would seem then that patients underestimate the effect of 3rd molar removal on quality of life and the time they will need to recover6. All of the above point to a need for us to be clearer in our communication with our patients when we brief them about the operation and what to expect, especially when it comes to issues such as lowered self-esteem, reduced condence, time off work, ability to eat and enjoyment of food (as well as all the other risks, e.g. nerve damage, trismus, swelling, we commonly include). Patient information sheets should include this information and consideration should be given to using other forms of visual media to communicate this. After all, if we are going to the PROMs, we do not want to be found wanting. Professor Graham R. Ogden Associate Editor email: g.r.ogden@dundee.ac.uk

References
1. Coulthard P. Minor oral surgery outcomes. Oral Surg 2013;6:167.
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2. Carmichael FA, McGowan DA. Incidence of nerve damage following third molar removal: a West of Scotland Oral Surgery Research Group study. Br J Oral Maxillofac Surg 1992;30:7882. 3. Brann CR, Brickley MR, Shepherd JP. Factors inuencing nerve damage during lower third molar surgery. Br Dent J 1999;186:51416. 4. Savin J, Ogden GR. Third molar surgery a preliminary report on aspects affecting quality of life in the early

post-operative period. Br J Oral Maxillofac Surg 1997;35: 24653. 5. Ogden GR, Bissias E, Ruta DA, Ogston S. Quality of life following third molar removal: a patient versus professional perspective. Br Dent J 1998;185:40711. 6. Edwards DJ, Horton J, Shepherd JP, Brickley MR. Impact of third molar removal on demands for postoperative care and job disruption: does anaesthetic choice make a difference? Ann R Coll Surg Engl 1999;81:11923.

Oral Surgery 7 (2014) 12. 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd