J Oral Maxillofac Surg

65:901-917, 2007
Assessing Postoperative Discomfort After
Third Molar Surgery: A Prospective Study
Giovanni Battista Grossi, MD, DMD, DDS,*
Carlo Maiorana, MD, DDS,
Rocco Alberto Garramone, MD, DDS,
Andrea Borgonovo, DMD, MD, Luca Creminelli, DDS,
and Franco Santoro, MD, DDS
Purpose: The purpose of this study was to identify the risk factors for severe discomfort after
mandibular third molar surgery and to assess the validity of the Postoperative Symptom Severity (PoSSe)
scale.
Patients and Methods: In a 2-year prospective study, a total of 255 unilateral impacted mandibular
third molar teeth were surgically removed under local anesthesia by 3 surgeons. Standardized surgical
and analgesic protocols were followed. At the review appointment, 1 week after surgery, all patients
returned a completed follow-up questionnaire (PoSSe scale) and were evaluated clinically for postoper-
ative pain (number of painkillers taken) and trismus (differences in mouth opening). Sixteen predictive
variables were evaluated using stepwise logistic regression analysis to identify the risk factors associated
with severe discomfort.
Results: Severe postoperative discomfort was predicted by these independent variables: gender,
tobacco use, ramus relationship/space available, and antibiotic prophylaxis. Oral contraceptive use and
operation time were not identied as risk factors. The patients perceptions of the severity of symptoms
(PoSSe scale score) was strongly correlated with clinical assessment of trismus (r 0.54) and pain (r
0.42).
Conclusion: The PoSSe scale resulted in a valid and responsive measure of the severity of symptoms
after surgical extraction of lower third molars and reected the clinical severity of the postoperative
discomfort. From a patients perspective, operative factors had little bearing on the quality of life after
removal of mandibular third molars.
2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:901-917, 2007
The surgical removal of impacted mandibular third
molars is one of the most commonly performed
dentoalveolar procedures in oral and maxillofacial
surgery and is associated with various postopera-
tive sequelae. Permanent nerve damage and serious
infections are the most severe complications fol-
lowing third molar extractions, but the rate of such
complications is low.
1-4
Pain, trismus, and swelling
are the most common postoperative complaints
and inuence the patients quality of life in the days
following surgery.
5,6
Moreover, removal of third
molar is so common that the population morbidity
of such minor complications may be signicant.
Surgeons perceptions of the consequences of third
molar surgery on their patients quality of life show
signicant differences from those of patients.
7
Over
the past 3 decades, the use of patient-centered
outcome scales in general medicine and surgery has
increased substantially, but has only recently been
used in oral surgery.
8,9
To date, there has been little
published on patients perceptions on quality of life
and risk factors for severe discomfort after removal
of a third molar.
5-7,9-13
Received from the Department of Oral Surgery, School of Dentistry,
University of Milan, Milan, Italy.
*Clinical Assistant Profesor.
Associate Professor.
Resident.
Resident.
Clinical Assistant Professor.
Department Head.
Address correspondence and reprint requests to Dr Grossi: Oral
Surgery, School of Dentistry, Istituti Clinici di Perfezionamento, Via
Commenda n10, 20122 Milano, Italy; e-mail: Giovanni.Grossi@
unimi.it or gb.grossi@icp.mi.it
2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6505-0013$32.00/0
doi:10.1016/j.joms.2005.12.046
901
The aim of this study was:
1) To measure patients perceptions of changes in
their quality of life after mandibular third molar
surgery with a specic questionnaire (PoSSe
scale).
13
2) To measure the clinical severity of trismus and
pain (differences in mouth opening and total
analgesic consumption).
3) To identify preoperative and intraoperative risk
factors for severe postoperative discomfort.
4) To assess the clinical validity of the PoSSe scale.
Patients and Methods
Between September 2002 and September 2004,
at the Oral Surgery Department, I.C.P. Hospital,
University of Milan (Italy), 213 consecutive patients
who had 266 extractions of mandibular third mo-
lars were prospectively studied. Fifty-three patients
who needed bilateral extractions had their teeth
removed on separate occasions with at least 1
month between them. Only 1 lower third molar
was removed at each operation and all teeth were
partially or completely covered by mucosa. One
inclusion criterion for this study was that a muco-
periosteal ap was to be raised during the opera-
tion, so 11 molars were excluded from analysis and
a total of 255 mandibular third molars were there-
fore available for analysis.
Participants were healthy individuals with no sys-
temic diseases or history of treatment for psychiat-
ric problems. The patients were not taking any
medications, except for females who regularly took
oral contraceptives. Exclusion criteria included pa-
tients who were pregnant or lactating. All patients
were free of caries, extensive periodontal disease,
pain, or other inammatory symptoms at the time
of operation. Patients who were already taking an-
timicrobials or had done so up to 2 weeks prior
were excluded. Informed written consent was ob-
tained from all patients before they were included
in this study.
DATA COLLECTION
At the initial visit and at the follow-up on the sev-
enth postoperative day, the information was recorded
by a single clinical examiner: the surgeons that had
operated on the patients were never involved in the
preoperative or postoperative assessment.
Preoperative Assessment
After consenting to participate in the study, the
following data were recorded: name, age, gender, site
of surgery, current tobacco and oral contraceptives
use, reasons for seeking third molar removal, and
maximum interincisal distance. Third molar position
was evaluated on the presurgical panoramic radio-
graph using Winters and Pell and Gregory classica-
tion (Table 1).
Patients were scheduled for operation with no cor-
relation between patient and surgeon, so that a ran-
dom surgeon operated on the patient.
Medications
Patients were randomly allocated into 2 groups. In
the rst group (n 119), prophylactic preoperative
oral antibiotic was administered with 2 g amoxicillin/
clavulanic acid 1 hour before surgery (Augmentin;
GlaxoSmithKline, Verona, Italy). The second group
(n 136) received no antibiotic medication and
served as the control. The surgeons were unaware
whether the prophylaxis was given or not.
A mouth rinse with 15 mL of 0.2% chlorhexidine
solution (Dentosan; Pzer Consumer Healthcare,
Rome, Italy) for 1 minute was used before surgery and
immediately after the operation. The day after sur-
gery, patients began home use of the chlorhexidine
solution twice a day for 1 week.
Table 1. DESCRIPTIVE STATISTICS FOR
PREOPERATIVE VARIABLES
Preoperative Variables Category n %
Age (yrs) 22 63 24.7
Average (27.04) 2329 117 45.9
Range (1467) 29 75 29.4
Gender M 120 47.1
F 135 52.9
Tobacco use Yes 76 29.8
No 179 70.2
Oral contraceptive
use
Yes 45 33.3
No 90 66.7
Antibiotic prophylaxis Yes 119 46.7
No 136 53.3
Indication for removal Infection 79 31.0
Periodontal disease 19 7.4
Prophylactic removal 80 31.4
Orthodontic reason 13 5.1
Caries 37 14.5
Atypical facial pain 27 10.6
Radiographic ndings
No. of roots Multiple 161 63.1
Singular 90 35.3
Incomplete 4 1.6
Spatial relationship Distoangular 52 20.4
Horizontal 59 23.2
Vertical 72 28.2
Mesioangular 72 28.2
Depth Level A (high) 43 16.9
Level B (medium) 166 65.1
Level C (deep) 46 18.0
Ramus relationship/
space available
Class I (sufcient) 9 3.5
Class II (reduced) 217 85.1
Class III (none) 29 11.4
Grossi et al. Assessing Discomfort After Third Molar Surgery.
J Oral Maxillofac Surg 2007.
902 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
Oral Coefferalgan (paracetamol 500 mg with co-
deine 30 mg; Bristol-Myers Squibb, Sermoneta, Italy)
was immediately given after the surgery and was pre-
scribed to be taken as required for pain relief (maxi-
mum, 6 tablets daily). Patients were instructed not to
take any drugs other than those prescribed and not to
seek medical help elsewhere for postoperative prob-
lems.
Surgery
A total of 3 surgeons with more than 5 years
dentoalveolar training, assisted by training house sur-
geons, performed the surgeries. Each patient had sim-
ilar surgical procedures, in the same operating room
and under similar conditions, using mepivacaine 2%
with epinephrine 1:100.000 as local anesthetic (2%
Carbocaine; AstraZeneca, Milan, Italy). No concomi-
tant medication was used during surgery other than
the local anesthetic. Access to the third molar was
achieved from the buccal aspect and bone was re-
moved with a round bur in a straight handpiece under
continuous irrigation with sterile saline solution. If
necessary, sectioning of crown and roots was per-
formed with a ssure bur. After tooth extraction, the
alveolus was inspected, curetted for granulation tis-
sue removal, and irrigated with sterile saline solution.
A 4/0 silk suture was used to close the wound without
tension. An ice pack was then applied to the patients
face for 20 minutes.
Immediately after the operation, details of the pro-
cedure were recorded, including the duration of sur-
gery in minutes (from the rst incision to insertion of
the last suture) (Table 2).
Patients were given the usual postoperative instruc-
tions and received 2 questionnaires, after being in-
structed in their use: the PoSSe scale
13
and a 9-point
scale to record pain levels.
14
Postoperative Assessment
All patients returned 1 week after the operation to
have their sutures removed: the examiner was the
same as the one who assessed them preoperatively.
Trismus was assessed by measuring the differences
in mouth opening (interincisal distance preopera-
tively and on postsurgery day 7).
The patients pain level were assessed with a
9-point visual analog scale anchored by the verbal
descriptors no pain (point 0) and very severe pain
(point 8).
14
Patients were advised to take the analge-
sic tablet as soon as their pain reached a moderate
level. They were asked to enter their pain level and
the time at which the analgesic was taken, and then
make no further recordings.
The PoSSe scale
13
was designed to assess the pa-
tients perception of adverse effects in 7 subscales:
eating, speech, sensation, appearance, pain, sickness,
and interference with daily activities. A score was
assigned to the possible responses to each forced
question. The scores of the responses to each ques-
tion were summed. These scores represent a percent-
age, so that a patient completing the questionnaire
and ticking the most severe response category for
each question would score 100%. A patient ticking
the least severe response category for each question
would score 0%.
Table 2. DESCRIPTIVE STATISTICS FOR OPERATIVE VARIABLES
Operative Variables Category n %
Surgeon 1 50 19.6
2 124 48.6
3 81 31.8
Assistant surgeon Clinical dental student 133 52.2
Resident 78 30.6
Specialist training 44 17.2
Flap design Envelope ap 59 23.1
Vestibular triangular ap 48 18.9
Vestibular trapezoidal ap 148 58.0
Bone removal Yes 200 78.4
No 55 21.6
Extraction difculty Elevator/forceps alone 49 19.2
Bone removal/tooth sectioning 46 18.0
Bone removal tooth/root sectioning 129 50.6
Extremely difcult 31 12.2
Operation time (min) 10 49 19.2
1120 83 32.5
2130 69 27.1
30 54 21.2
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
GROSSI ET AL 903
Table 3. DESCRIPTIVE STATISTICS AND ANALYSIS OF VARIANCE (1-WAY ANOVA) OF INDEPENDENT VARIABLES
VERSUS FULL POSSE SCALE
Independent Variables (Preoperative and
Operative)
Dependent Variable Full PoSSe Scale
P Value Range (min) Range (max) Mean Median
Age (yrs)
22 7.13 61.88 32.70 33.38 .09
2329 5.11 81.65 36.12 34.48
29 5.38 67.93 37.64 35.83
Gender
M 7.13 67.89 33.62 33.09 .01
F 5.11 81.65 37.59 37.09
Tobacco use
Yes 9.91 67.89 37.76 36.35 .11
No 5.11 81.65 34.85 33.62
Oral contraceptive use
Yes 5.11 60.88 34.88 36.01 .11
No 5.38 81.65 38.95 37.60
Antibiotic prophylaxis
Yes 5.38 62.64 32.89 31.61 .001
No 5.11 81.65 38.20 37.01
Indication for removal
Infection 11.21 81.65 36.16 35.09 .78
Periodontal disease 15.74 62.64 35.70 32.27
Prophylactic removal 5.11 66.28 35.97 35.78
Orthodontics reason 20.49 67.93 38.62 38.59
Caries 5.38 60.88 32.83 32.16
Atypical facial pain 14.81 60.64 36.27 33.46
Number of roots
Multiple 5.11 67.93 35.34 34.46 .75
Singular 7.13 81.65 36.51 35.75
Incomplete 20.49 44.79 33.23 33.82
Spatial relationship
Distoangular 14.97 81.65 38.28 36.34 .44
Horizontal 5.38 64.16 34.22 33.62
Vertical 5.11 67.89 35.61 34.60
Mesioangular 7.13 61.88 35.21 34.07
Depth
Level A (high) 11.21 55.04 32.72 30.99 .27
Level B (medium) 5.11 81.65 36.46 35.59
Level C (deep) 7.13 62.64 35.84 35.94
Ramus relationship/space available
Class I (sufcient) 17.87 41.13 31.22 33.46 .002
Class II (reduced) 5.11 81.65 34.85 33.62
Class III (none) 25.59 67.93 43.60 43.52
Surgeon
1 7.13 62.64 32.56 31.35 .06
2 8.01 81.65 37.62 35.78
3 5.11 67.93 34.76 33.83
Assistant surgeon
Clinical dental student 7.13 81.65 35.70 34.43 .70
Resident 8.01 67.89 36.51 35.40
Specialist training 5.11 67.93 34.38 33.49
Flap design
Envelope ap 5.11 56.46 32.07 31.41 .06
Vestibular triangular ap 9.01 67.93 36.80 35.77
Vestibular trapezoidal ap 5.38 81.65 36.82 34.56
Bone removal
Yes 5.38 81.65 36.80 34.68 .01
No 5.11 56.46 31.78 32.02
Extraction difculty
Elevator/forceps alone 5.11 56.46 31.97 32.02 .11
Bone removal/tooth sectioning 10.27 81.65 38.29 35.70
Bone removal tooth/root sectioning 5.38 67.93 35.79 34.43
Extremely difcult 7.13 62.64 37.55 36.01
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
904 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
Study Variables, Data Management,
and Analysis
The set of predictor variables was divided into 2
groups: preoperative and operative variables (Tables
1 and 2).
The outcome variables were:
1) PoSSe score (derived from the PoSSe scale by
adding the responses to each of the individual
questions).
2) Trismus (range of opening measured preopera-
tively and on postsurgery day 7).
3) Pain (total analgesic consumption).
Data were entered into a spreadsheet (Excel; Mi-
crosoft, Inc, Redmond, WA) over the course of the
study. With use of a statistical software package (SPSS
for Windows, version 12.0; SPSS Inc, Chicago, IL,
2003), descriptive statistics were computed for all of
the study variables.
All pertinent data were subsequently analyzed with
the 1-sample Kolmogorov-Smirnov test with respect
to normality.
According to normality, initial statistical analyses
used parametric (1-way ANOVA) or nonparametric
test (Mann-Whitney U test or Kruskal-Wallis rank test)
to measure the association between each predictor
variable (preoperative and operative) and outcome
variables (full PoSSe score, single PoSSe subscales,
Trismus, and Pain). To measure the association be-
tween the predictor and outcome variables while con-
trolling for confounders, a logistic regression model
was used. Biologically relevant variables (age and gen-
der) and variables that had P .20 in the initial
analyses were entered into logistic regression model
as independent variables. All parameters used as out-
come variables were dichotomized before entering
the logistic regression: scores with a value of the
median value were recorded as 0, those of the
median value were recorded as 1. The data were
allowed to enter the model using backward selection
with the signicance level to remove set at 0.1. Pear-
son
2
test was performed to test the goodness of t
of the nal model. Spearmans rank correlation coef-
cient was used to assess the correlation between the
outcome variables.
A value of P .05 was accepted as statistically
signicant.
Results
Two hundred fty-ve patients (135 females, 120
males) aged 14 to 67 years (average, 27.04 years)
representing 255 extraction sites of mandibular third
molars were entered into this study. The descriptive
statistics for the sample are summarized in Tables 1
and 2.
RISK FACTORS FOR SEVERE DISCOMFORT
(MEASURED WITH THE POSSE SCALE)
The mean PoSSe score (SD) was 35.72 13.54
(range, 5.1181.65). The results of descriptive statis-
tics and of analysis of variance are shown in Table 3.
The logistic regression analysis revealed risk factors
for severe discomfort (Table 4). Only 4 out of 16
independent variables, all preoperative, were signi-
cant indicators for severe discomfort: gender, tobacco
use, antibiotic prophylaxis, and ramus relationship/
space available.
Females had twice the odds of males of severe
discomfort (odds ratio [OR] 2.07; P .01). Espe-
cially, females were found to be at 6 times higher
risk of feeling sickness (OR 6.20; P .000) than
males, and had a 2 to 2.5 times higher risk of
experiencing interference with daily activities,
problems in eating and speaking, and changes of
appearance (Table 5).
Smokers were found to have a higher risk for re-
porting more severe discomfort (OR 1.86; P .04),
Patients who did not receive prophylactic antibiotics
also reported more discomfort (OR 2.05; P .007).
Finally, when evaluating the radiographic ndings,
the ramus relationship/space available was the only
variable found to increase the risk of severe discom-
fort. If the third molar had insufcient space available
in relation to the ramus it was more likely that the
Table 3. (Contd)
Independent Variables (Preoperative and
Operative)
Dependent Variable Full PoSSe Scale
P Value Range (min) Range (max) Mean Median
Operation time (min)
10 5.11 81.65 33.05 32.76 .49
1120 5.38 67.93 36.08 34.43
2130 9.91 60.88 36.44 35.56
30 7.13 62.64 36.67 34.45
Total 5.11 81.65 35.72 34.46
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
GROSSI ET AL 905
patient scored high on the PoSSe scale than if the
third molar had sufcient space available (Class III,
OR 6.24, P .04; Class II, OR 2.18, P .34).
RISK FACTORS FOR TRISMUS
The mean difference of mouth opening (SD) was
8.9 mm 8.2 (range, 0.036.0). Details of descriptive
statistics and nonparametric tests are shown in Table 6.
Like that found in the precedent logistic regression
model, gender, antibiotic prophylaxis, smoking hab-
its, and ramus relationship/space available were
statistically signicant predictors of severe trismus
(Table 7). Moreover, in this model there was a higher
risk of trismus if the molar was deeply impacted or
the patients were over 23 years of age.
Finally, 2 operative variables were found to be
statistically signicant predictors of the occurrence of
severe trismus: bone removal and surgeon.
RISK FACTORS FOR PAIN
The mean number of analgesic tablets taken post-
operatively (SD) was 5.2 4.3 (range, 0.021.0).
Details of descriptive statistics and nonparametric
tests are shown in Table 8.
The only signicant preoperative indicator for se-
vere postoperative pain was antibiotic prophylaxis
(Table 9): patients who received no antibiotic medi-
cation were found to have a higher risk for analgesic
consumption than those who received prophylaxis
(OR 2.20; P .005).
Two operative variables were found to be an
indicator for postoperative pain. When surgery was
perceived as being extremely difcult and a trape-
zoidal ap was raised, the patients had approxi-
mately 3 times the odds of feeling severe postoper-
ative pain.
Table 4. RISK FACTORS FOR SEVERE DISCOMFORT (INDEPENDENT VARIABLES VERSUS FULL POSSE SCALE)
Independent Variables Category
Total
No.
PoSSe 0
No.
PoSSe 1
No. Odds Ratio CI 95% P Value
Gender M 120 73 47 1.00 1.183.60 .01
F 135 65 70 2.07
Tobacco use No 179 102 77 1.00 1.023.40 .04
Yes 76 36 40 1.86
Antibiotic prophylaxis Yes 119 75 44 1.00 1.213.45 .007
No 136 63 73 2.05
Ramus relationship/
space available
Class I (sufcient) 9 7 2 1.00 0.4211.19 .34
Class II (reduced) 217 121 96 2.18 1.0437.47 .04
Class III (none) 29 10 19 6.24
NOTE. Logistic regression analysis: backward selection (P-to-remove: 0.1); goodness of t: Pearson
2
test 186.50 (P .28). Odds ratio, 95%
condence intervals (CI) and P values.
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
Table 5. RISK FACTORS FOR SEVERE DISCOMFORT (INDEPENDENT VARIABLES VS EACH POSSE SUBSCALE-GENDER)
PoSSe Subscales Category
Total
No.
PoSSe 0
No.
PoSSe 1
No. Odds Ratio CI 95% P Value
Eating M 120 71 49 1.00
F 135 63 72 2.40 1.374.20 .002
Speech M 120 74 46 1.00
F 135 66 69 2.02 1.183.45 .01
Sensation M 120 85 35 NS
F 135 93 42
Appearance M 120 65 55 1.00
F 135 60 75 2.52 1.404.55 .002
Pain M 120 63 57 NS
F 135 65 70
Sickness M 120 109 11 1.00
F 135 83 52 6.20 3.0512.63 .000
Interference with daily activities M 120 68 52 1.00
F 135 52 83 2.08 1.263.44 .004
NOTE. The table shows the gender-related odds ratio.
Abbreviation: NS, the independent variable was not a statistically signicant predictor of severe discomfort.
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
906 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
Table 6. DESCRIPTIVE STATISTICS AND LEVELS OF SIGNIFICANCE (INDEPENDENT VARIABLES VS TRISMUS)
Independent Variables (Preoperative and
Operative)
Dependent Variable Trismus (Difference
in Mouth Opening in mm)
Kruskal-Wallis
Rank Test
Mann-Whitney
U Test
Range (min) Range (max) Mean Median P Value P Value
Age (yrs)
22 0.0 35.0 6.5 5.0 .002
2329 0.0 35.0 9.0 7.0
29 0.0 36.0 10.6 8.0
Gender
M 0.0 36.0 8.8 5.5 .40
F 0.0 31.0 8.9 7.0
Tobacco use
Yes 0.0 35.0 10.2 8.0 .18
No 0.0 36.0 8.3 6.0
Oral contraceptive use
Yes 0.0 30.0 7.3 5.0 .02
No 0.0 31.0 9.8 8.0
Antibiotic prophylaxis
Yes 0.0 25.0 6.8 5.0 .001
No 0.0 36.0 10.8 8.0
Indication for removal
Infection 0.0 31.0 9.1 7.0 .36
Periodontal disease 0.0 36.0 9.3 6.0
Prophylactic removal 0.0 35.0 9.4 7.0
Orthodontics reason 0.0 25.0 11.6 11.0
Caries 0.0 33.0 6.4 5.0
Atypical facial pain 0.0 30.0 8.6 6.0
Number of roots
Multiple 0.0 36.0 9.3 7.0 .53
Singular 0.0 31.0 8.1 6.0
Incomplete 0.0 24.0 10.7 9.5
Spatial relationship
Distoangular 0.0 35.0 10.1 7.5 .70
Horizontal 0.0 33.0 9.0 7.0
Vertical 0.0 31.0 8.1 5.5
Mesioangular 0.0 36.0 8.7 6.0
Depth
Level A (high) 0.0 25.0 5.9 5.0 .02
Level B (medium) 0.0 36.0 9.7 7.0
Level C (deep) 0.0 30.0 8.7 7.0
Ramus relationship/space available
Class I (sufcient) 0.0 13.0 4.5 5.0 .0008
Class II (reduced) 0.0 35.0 8.5 6.0
Class III (none) 2.0 36.0 13.1 12.0
Surgeon
1 0.0 36.0 6.7 4.5 .04
2 0.0 35.0 9.4 7.0
3 0.0 35.0 9.4 7.0
Assistant surgeon
Clinical dental student 0.0 33.0 7.6 6.0 .04
Resident 0.0 36.0 11.1 7.5
Specialist training 0.0 35.0 8.8 5.5
Flap design
Envelope ap 0.0 26.0 6.3 5.0 .009
Vestibular triangular ap 0.0 35.0 10.6 6.5
Vestibular trapezoidal ap 0.0 36.0 9.3 7.0
Bone removal
Yes 0.0 36.0 9.8 7.0 .0001
No 0.0 26.0 5.5 3.0
Extraction difculty
Elevator/forceps alone 0.0 26.0 5.9 5.0 .01
Bone removal/tooth sectioning 0.0 31.0 9.0 6.0
Bone removal tooth/root sectioning 0.0 36.0 9.5 7.0
Extremely difcult 0.0 35.0 10.7 8.0
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
GROSSI ET AL 907
VALIDATION OF THE POSSE SCALE
The patients score on the PoSSe scale had signif-
icant positive correlations with both differences in
mouth opening (r 0.54) and total analgesic con-
sumption (r 0.41) (Table 10). Correlations be-
tween the 7 PoSSe subscales and the 2 clinical
dependent variables are shown in Table 10. The
total analgesic consumption consistently gave
stronger correlations with the pain subscale than
the other (r 0.60). Similarly, differences in mouth
opening strongly correlated with the eating sub-
scale (r 0.53). Table 11 shows the correlations
between the subscale scores and the overall PoSSe
score.
Figures 1 through 4 show the impact of gender on
outcome variables when such independent variables
interact with other risk factors.
Table 12 provides an overview of the risk factors for
a severe discomfort found in this study. The antibiotic
prophylaxis was the only variable found statistically sig-
nicant in all 3 regression logistic models of this study.
Discussion
Much has been written about the relationships be-
tween the postoperative morbidity after surgical re-
moval of lower third molars and preoperative risk
factors. However, little has been published on the
patients perceptions on quality of life after this op-
eration. Moreover, most of these studies have tested
the individual variables isolated without adjusting for
the other potential risk indicators, several reporting
only descriptive data, making interpretation difcult
because of inadequate analyses.
Table 6. (Contd)
Independent Variables (Preoperative and
Operative)
Dependent Variable Trismus (Difference
in Mouth Opening in mm)
Kruskal-Wallis
Rank Test
Mann-Whitney
U Test
Range (min) Range (max) Mean Median P Value P Value
Operation time (min)
10 0.0 31.0 6.7 5.0 .07
1120 0.0 35.0 9.0 5.0
2130 0.0 31.0 9.0 7.0
30 0.0 36.0 10.6 8.5
Total 0.0 36.0 8.9 6.0
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
Table 7. RISK FACTORS FOR SEVERE TRISMUS
Independent Variables Category
Total
No.
PoSSe 0
No.
PoSSe 1
No. Odds Ratio CI 95% P Value
Age (yrs) 22 63 47 16 1.00
2329 117 70 47 2.93 1.316.56 .009
29 75 39 36 3.23 1.387.58 .007
Gender M 120 79 41 1.00
F 135 77 58 3.04 1.555.96 .001
Tobacco use No 179 115 64 1.00
Yes 76 41 35 2.14 1.094.22 .02
Antibiotic prophylaxis Yes 119 85 34 1.00
No 136 71 65 3.11 1.675.78 .000
Depth Level A (high) 43 35 8 1.00
Level B (medium) 166 93 73 3.15 1.228.14 .01
Level C (deep) 46 28 18 2.45 0.787.64 .12
Ramus relationship/space
available
Class I (sufcient) 9 8 1 1.00
Class II (reduced) 217 138 79 1.48 0.1514.04 .72
Class III (none) 29 10 19 6.52 0.5971.88 .12
Surgeon 1 50 39 11 1.00
2 124 71 53 3.53 1.468.51 .005
3 81 46 35 3.77 1.489.61 .005
Bone removal No 55 45 10 1.00
Yes 200 111 89 3.95 1.669.41 .002
NOTE. Logistic regression analysis: backward selection (P-to-remove: 0.1); goodness of t: Pearson
2
test 234.07 (P .32). Odds ratio, 95%
condence intervals (CI) and P values.
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
908 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
Table 8. DESCRIPTIVE STATISTICS AND LEVELS OF SIGNIFICANCE (INDEPENDENT VARIABLES VS PAIN)
Independent Variables (Preoperative and
Operative)
Dependent Variable-Pain (No. of
Painkillers Taken)
Kruskal-Wallis
Rank Test
Mann-Whitney
U Test
Range (min) Range (max) Mean Median P Value P Value
Age (yrs)
22 0.0 21.0 4.0 2.0 .01
2329 0.0 18.0 5.5 4.0
29 0.0 17.0 5.7 5.0
Gender
M 0.0 21.0 5.5 4.0 .21
F 0.0 17.0 4.9 4.0
Tobacco use
Yes 0.0 21.0 6.2 5.0 .002
No 0.0 18.0 4.8 3.0
Oral contraceptive use
Yes 0.0 17.0 5.3 4.0 .41
No 0.0 16.0 4.7 3.0
Antibiotic prophylaxis
Yes 0.0 18.0 4.7 4.0 .20
No 0.0 21.0 5.6 4.5
Indication for removal
Infection 0.0 16.0 4.8 4.0 .77
Periodontal disease 0.0 12.0 4.4 3.0
Prophylactic removal 0.0 21.0 6.0 5.0
Orthodontics reason 1.0 11.0 5.4 5.0
Caries 0.0 14.0 5.1 3.0
Atypical facial pain 0.0 17.0 4.8 3.0
No. of roots
Multiple 0.0 21.0 5.2 4.0 .55
Singular 0.0 16.0 5.1 3.0
Incomplete 2.0 9.0 6.5 7.5
Spatial relationship
Distoangular 0.0 16.0 6.6 6.0 .04
Horizontal 0.0 14.0 4.7 4.0
Vertical 0.0 14.0 4.4 3.5
Mesioangular 0.0 21.0 5.4 3.5
Depth
Level A (high) 0.0 13.0 4.6 3.0 .75
Level B (medium) 0.0 21.0 5.3 4.0
Level C (deep) 0.0 18.0 5.4 4.0
Ramus relationship/space available
Class I (sufcient) 0.0 9.0 3.3 3.0 .07
Class II (reduced) 0.0 21.0 5.1 4.0
Class III (none) 1.0 18.0 6.5 6.0
Surgeon
1 0.0 11.0 3.9 3.0 .002
2 0.0 21.0 6.1 5.0
3 0.0 14.0 4.6 3.0
Assistant surgeon
Clinical dental student 0.0 18.0 5.3 4.0 .78
Resident 0.0 21.0 5.1 4.0
Specialist training 0.0 14.0 5.0 4.0
Flap design
Envelope ap 0.0 14.0 4.9 3.0 .009
Vestibular triangular ap 0.0 14.0 4.2 3.0
Vestibular trapezoidal ap 0.0 21.0 5.6 4.0
Bone removal
Yes 0.0 21.0 5.2 4.0 .91
No 0.0 14.0 5.2 4.0
Extraction difculty
Elevator/forceps alone 0.0 14.0 5.3 4.0 .10
Bone removal/tooth sectioning 0.0 12.0 4.1 3.0
Bone removal tooth/root sectioning 0.0 17.0 5.1 4.0
Extremely difcult 0.0 21.0 6.9 6.0
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
GROSSI ET AL 909
The following describes the outcomes of the study
and how our ndings might inuence the outcome of
previously published studies on risk factors for com-
plications after third molar surgery.
PREOPERATIVE RISK FACTORS
Age
Removal of impacted third molar should not be
considered the best model for studying the age-re-
lated differences because such operation is usually
carried out on teenagers and young adults. However,
it is commonly thought that older patients are at
greater risk for complications after third molar sur-
gery.
3,15,16
In our study, the patients age was found to be a
risk factor only for severe trismus; that is, patients
aged 22.0 years were found to have a lower risk
than older patients.
Recently, Benediktsdttir et al
17
studied the risk
indicators for postoperative complications after re-
moval of 388 mandibular third molars: older age (23
years) was found to increase the risk of an extended
operation time (10 minutes), but operation time
itself was not found to be a risk indicator for postop-
erative complications. In the present study, after ad-
justment for other risk factors, no signicant associa-
tion was found between age and the PoSSe score or
total painkillers consumption. This means that older
patients are at greater risk of severe trismus after third
molar surgery, but younger patients have the same
odds of perceiving severe discomfort and pain. If
other similar studies conrm these data, it will likely
be wrong to advocate the early prophylactic removal
of the lower third molar claiming lower risk of post-
operative discomfort.
Gender
There is general agreement that women and men
perceive and respond differently to pain stimuli.
18-20
Moreover, biologic differences exist between men
and women that can result in differences in responses
to drugs.
21-26
The most common nding after removal of third
molar is that women reported more postsurgical pain
that men.
11,12,14,17
In contrast, Capuzzi et al,
27
in 146
patients having third molar surgery, reported that
Table 8. (Contd)
Independent Variables (Preoperative and
Operative)
Dependent Variable-Pain (No. of
Painkillers Taken)
Kruskal-Wallis
Rank Test
Mann-Whitney
U Test
Range (min) Range (max) Mean Median P Value P Value
Operation time (min)
10 0.0 12.0 5.0 4.0 .73
1120 0.0 17.0 5.0 3.0
2130 0.0 16.0 4.9 4.0
30 0.0 21.0 6.0 4.5
Total 0.0 21.0 5.2 4.0
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
Table 9. RISK FACTORS FOR SEVERE PAIN (NUMBER OF PAINKILLERS TAKEN)
Independent Variables Category
Pain (No. of Painkillers
Taken)
Odds Ratio CI 95% P Value
Total
No.
PoSSe 0
No.
PoSSe 1
No.
Antibiotic prophylaxis Yes 119 80 39 1.00
No 136 74 62 2.20 1.273.81 .005
Flap design Envelope ap 59 35 24 1.87 0.695.09 .21
Vestibular triangular ap 48 35 13 1.00
Vestibular trapezoidal ap 148 84 64 2.87 1.326.24 .007
Extraction difculty Elevator/forceps alone 49 27 22 2.42 0.866.82 .09
Bone removal/tooth sectioning 46 32 14 1.00
Bone removal tooth/root
sectioning
129 82 47 1.34 0.632.85 .44
Extremely difcult 31 13 18 3.32 1.248.91 .01
NOTE. Logistic regression analysis: backward selection (P-to-remove: 0.1); goodness of t: Pearson
2
test 235.45 (P .20). Odds ratio, 95%
condence intervals (CI) and P values.
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
910 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
there was no gender-related differences in regard to
the number of analgesic tablets taken.
In the present study, gender was not found to be a
risk factor for objectively measured pain (total pain-
killer consumption), or for subjectively measured
pain (pain subscale score).
On the other hand, among our cohort of patients,
females had more than 3 times higher risk for severe
trismus compared with males, and these ndings are
in agreement with previous studies.
11,12
For gender differences in symptom reporting, the
data show that females had twice the odds of males of
perceiving a severe postoperative discomfort (full
PoSSe score). Especially, except for pain and sensa-
tion subscales that have not shown differences to be
gender-related, females were found to complain more
than males about sickness (OR 6.2; P .000),
appearance (OR 2.52; P .002), eating (OR
2.40; P 0.002), speech (OR 2.0; P .01) and
interference with daily activities (OR 2.0; P
.004) (Table 5).
It can be proposed that the strong gender-related
difference found for sickness may be attributable to
the type of painkiller prescribed in our study, a
codeine-combined drug. In fact, it was shown that
women had 60% higher risk of nausea and vomiting
than men when taking opioid agonists, although
efcacy did not differ between the 2 groups.
28
Finally, it seems that some risk factors increase
gender differences. Smoking appears to increase
the PoSSe score and the total painkiller consump-
tion in females much more than in males (Figs 1 and
4). Women are less likely than men to benet from
antibiotic prophylaxis (Fig 2), and are more likely
than men to perceive severe discomfort when a
third molar with no space available was removed
(Fig 3).
It is commonly believed that situational and psy-
chological factors can play a major role in symptom
perception and that the gender differences cannot
simply be attributed to a greater physical morbidity
in women. Contrary to popular belief, recent studies
indicate that when an actual illness or disease is present,
however minor and transient, men and women are
either equally likely to report related symptoms, or
men report more severe symptoms.
29
However, being male or female is an important
fundamental variable that should be considered when
designing and analyzing the results of studies in all
areas and at all levels of biomedical and health-related
research. Therefore, subjects who have lower third
molars extracted should not be viewed as a uniform
population when postoperative discomfort is evalu-
ated, but should be stratied by gender.
Such data in relation to gender differences may
help surgeons to counsel female patients about recov-
ery after third molar surgery and will enhance the
informed consent procedures.
Tobacco Use
Smoking has been shown to have a deleterious
effect on the oral cavity and has been associated with
postoperative complications after oral surgery.
30-35
In the present study, patients who smoke were
found to have a higher risk for perceiving more severe
postoperative discomfort (OR 1.86; P .04) and
trismus (OR 2.14; P .02).
It was shown that women who smoke are more
likely to develop diseases than men.
36
This is consis-
tent with our nding that smoking appears to en-
hance gender differences in PoSSe score (Fig 1).
Interestingly, it has been reported that nicotine
increases the pain threshold and tolerance rating of
Table 11. SPEARMANS CORRELATION COEFFICIENT
TO ASSESS CORRELATION BETWEEN THE POSSE
SCALE AND SUBSCALES
Subscale Full PoSSe
Eating 0.83*
Speech 0.65*
Sensation 0.37*
Appearance 0.54*
Pain 0.67*
Sickness 0.35*
Interference with daily activities 0.71*
*P .01.
Grossi et al. Assessing Discomfort After Third Molar Surgery.
J Oral Maxillofac Surg 2007.
Table 10. VALIDITY TESTING, SPEARMANS
CORRELATION COEFFICIENT TO ASSESS
CORRELATION BETWEEN THE POSSE SCALE, POSSE
SUBSCALES, AND THE TWO CLINICAL DEPENDENT
VARIABLES (TRISMUS AND PAIN)
Subjective Dependent
Variable
Objective Dependent
Variable
Pain (No. of Painkillers
Taken) Trismus
Full PoSSe 0.41** 0.54**
Eating 0.26** 0.53**
Speech 0.21** 0.34**
Sensation 0.11 0.10
Appearance 0.13* 0.41**
Pain 0.60** 0.30**
Sickness 0.05 0.18**
Interference with daily
activities 0.29** 0.38**
*P .05.
**P .01.
Grossi et al. Assessing Discomfort After Third Molar Surgery.
J Oral Maxillofac Surg 2007.
GROSSI ET AL 911
men, but has no effect on the pain rating of women.
37
These ndings can be an explanation of why smokers
as a whole in this study were not found at higher risk
for pain and why female smokers consumed more
painkillers than male smokers (Fig 4).
Oral Contraceptive Use
Numerous studies reported increased complica-
tions among females associated with oral contracep-
tive use.
35,38-41
However, most of these studies have
not been optimally designed or analyzed to remove
the effects of various known confounders. This study
fails to conrm the hypothesis that oral contraceptive
use is a risk factor for severe postoperative discom-
fort, which is consistent with other studies.
16,33,42
However, data on the menstrual cycle of the women
were not gathered. Therefore, these ndings should
be interpreted with caution and further studies are
needed to consider the endocrine status of subjects in
analyses.
Antibiotic Prophylaxis
The routine use of systemic preoperative and/or
postoperative antibacterial given prophylactically is
FIGURE 1. Relationship between gender*
tobacco use versus full PoSSe score.
Grossi et al. Assessing Discomfort After
Third Molar Surgery. J Oral Maxillofac Surg
2007.
FIGURE 2. Relationship between gender*
antibiotic prophylaxis versus full PoSSe score.
Grossi et al. Assessing Discomfort After
Third Molar Surgery. J Oral Maxillofac Surg
2007.
912 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
highly disputed and by many considered to be con-
troversial because of the development of resistant
bacterial strains and possible systemic side effects,
such as hypersensitivity and unnecessary destruction
of host ora.
43-45
Several studies have shown that postoperative oral
prophylactic antibiotic treatment after the removal of
lower third molars does not contribute to a better
wound healing, less pain, or increased mouth open-
ing.
27,46,47
In contrast, Delilbasi et al
48
reported some
evidence of the benet of postoperative antibiotic for
the prevention of alveolar osteitis. However, surgical
principles dictate that if preventive antibiotics are
given to improve recovery, the drug should be admin-
istered just before surgery at a sufcient dosage to
ensure adequate blood and tissue levels, and discontin-
ued after surgery.
44,49,50
Nevertheless, Sekhar et al
51
failed to show any advantage in the routine preoper-
ative or postoperative use of metronidazole during
removal of third molars.
In this study, preoperative antibiotic prophylaxis
was found to be the only independent variable statis-
FIGURE 3. Relationship between gender*
ramus relationship/space available versus full
PoSSe score.
Grossi et al. Assessing Discomfort After
Third Molar Surgery. J Oral Maxillofac Surg
2007.
FIGURE 4. Relationship between gender*
tobacco use versus number of painkillers taken.
Grossi et al. Assessing Discomfort After
Third Molar Surgery. J Oral Maxillofac Surg
2007.
GROSSI ET AL 913
tically signicant (P .01) versus all outcome vari-
ables studied (Table 12).
Of note, women looked less likely than men to
benet from antibiotic prophylaxis (Fig 2). This nd-
ing could be explained by the gender differences in
pharmacokinetics and pharmacodynamics.
52
Above
all, gender differences in hepatic enzymes seem to
play a major role in determining pharmacokinetic
variability by gender.
22,52,53
Amoxicillin/clavulanic
acid was used as a prophylactic antibiotic treatment.
It was reported that erythromycin is cleared more
rapidly in women than men,
52
and there may be a
common metabolic pathway for both amoxicillin/cla-
vulanic acid and erythromycin.
54
Moreover, it was
shown that men are much more frequently affected
by amoxicillin/clavulanic acid-induced hepatitis than
women (male to female ratio, 4:1) and it is likely that
clavulanic acid is responsible for the hepatotoxicity.
54
It can be hypothesized that when clavulanic acid was
given to females, because of the faster hepatic metabo-
lism, it cannot provide enough anti--lactamase activity
capable to enhance the activity of amoxicillin. However,
these ndings have not been conrmed in the literature
and further studies are needed.
Indication for Removal
It has been suggested that the presence of symp-
toms at the time of mandibular third molar removal
must be considered to be a risk factor for postopera-
tive complications
55
or delay of wound healing.
12
In
the present study, we fail to conrm this hypothesis,
perhaps because all patients in this study were free of
caries, extensive periodontal disease, pain, or other
inammatory symptoms at the time of operation.
Radiographic Findings
Classically, the assessment of difculty of extrac-
tion has been based on angulation, depth of impac-
tion, ramus, and occlusal positions. Bui et al
16
re-
ported that mesioangular impactions were associated
with a higher risk for postoperative complications;
whereas Yuasa et al
56
found that depth and ramus
relationship/space available were associated with dif-
culty in extraction. We found that deeply impacted
molar and insufcient space available in relation to
the ramus were risk factors for severe postoperative
discomfort.
Different than operative variables (ie, operative
time and extraction difculty), information gathered
from a panoramic radiograph can help the surgeon
plan the surgery and inform the patient of the likeli-
hood of postoperative complications.
Operative Risk Factors
Many studies have emphasized that operative fac-
tors were strong indicators for postoperative compli-
cations.
From the patients perspective, in this study none
of the operative variables were found to be risk fac-
tors for severe discomfort (PoSSe score). If these data
are conrmed, the clinician could counsel a patient
before surgery about their outcome, with only a slight
chance that an event at surgery would drastically alter
what was advised presurgically.
Flap Design
There are very few specic data available from the
literature regarding postoperative ap-related discom-
fort. In this study, the triangular ap design was asso-
ciated with those consuming the least painkillers.
When a trapezoidal ap was raised the patients had
approximately 3 times the odds of taking an above-
average number of painkillers. Of note, although sur-
geons in this study used an envelope ap technique
when the lower third molar surgery was expected to
be easy, when access was achieved with such a ap
Table 12. OVERVIEW OF POSSIBLE RISK FACTORS
Dependent Variable
Preoperative Independent Variable Operative Independent Variable
A
G
E
G
E
N
D
E
R
T
O
B
A
C
C
O
U
S
E
O
R
A
L
C
O
N
T
R
A
C
E
P
T
I
V
E
U
S
E
A
N
T
I
B
I
O
T
I
C
P
R
O
P
H
Y
L
A
X
I
S
I
N
D
I
C
A
T
I
O
N
F
O
R
R
E
M
O
V
A
L
N
U
M
B
E
R
O
F
R
O
O
T
S
S
P
A
T
I
A
L
R
E
L
A
T
I
O
N
S
H
I
P
D
E
P
T
H
R
A
M
U
S
R
E
L
A
T
I
O
N
S
H
I
P
S
U
R
G
E
O
N
A
S
S
I
S
T
A
N
T
S
U
R
G
E
O
N
F
L
A
P
D
E
S
I
G
N
B
O
N
E
R
E
M
O
V
A
L
E
X
T
R
A
C
T
I
O
N
D
I
F
F
I
C
U
L
T
Y
O
P
E
R
A
T
I
O
N
T
I
M
E
Trismus
No. of painkillers taken
Full PoSSe score
, Statistically signicant predictor.
Grossi et al. Assessing Discomfort After Third Molar Surgery. J Oral Maxillofac Surg 2007.
914 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
patients had almost twice the odds of consuming
more painkillers than when a triangular ap was used.
These ndings are consistent with those from Jakse
et al,
57
who stated that the envelope ap has a nearly
6 times higher risk of dehiscence during primary
wound healing than the triangular ap. These authors
hypothesized that soft tissue tensions resulting from
postoperative hematoma and masticatory movements
may induce a rupture of the wound margin during the
rst few postoperative days. This would be more
likely when envelope ap is raised because it is xed
anteriorly with intersulcular sutures.
Extraction Difculty
It is commonly thought that there is a relationship
between operative trauma and the magnitude of post-
operative pain, and that the amount of mucoperios-
teum that has to be reected and of bone that has to
be removed affect the severity of postoperative pain
and swelling.
55
Evaluating the odds of consuming
painkillers, data from the present study conrm this
hypothesis (except for removal with elevator/forceps
alone, which had higher odds for severe pain than
bone removal/tooth root sectioning). It may be sug-
gested that sometimes raising a small ap without
bone removal and/or tooth/root sectioning is not a
good idea, causing patients to suffer more severe pain
presumably because of the excessive soft tissue dam-
age and delayed wound healing.
However, extraction difculty was not found statis-
tically signicant versus patients perceptions of dis-
comfort (PoSSe score). It is possible that patients
assessed postoperative third molar pain as better or as
expected. Another explanation may be that pain was
well controlled by painkillers.
Surgeon
It has been previously suggested that surgical ex-
perience is closely related to the postoperative com-
plication rate,
27,55
although other studies have failed
to show any relationship.
17,58
The skill of the surgeon
has been identied as a risk factor for severe trismus
but not for severe pain or for higher PoSSe score. A
possible explanation for these ndings could be that
all surgeons in this study had more than 5 years
dentoalveolar training and used the same surgical ap-
proach, in the same operating room, and under sim-
ilar conditions.
Operation Time
Several studies have stated that the length of the
operation could be used as a proxy variable for ex-
traction difculty.
59-61
Other studies reported that pa-
tients whose surgery time was 30 minutes or longer
had a prolonged recovery.
11,12
Consistent with previ-
ous studies, our results fail to conrm the hypothesis
that operation time is a risk factor for severe postop-
erative discomfort.
17,46
These ndings may be attrib-
utable to the fact that the variation was not large in this
study, that is, the mean operating time was 24.4 15.9
minutes. Interestingly, the surgeon whose patients
had less postoperative discomfort spent more time in
performing the operations (mean operating time
30.7 vs 23.6 and 21.8 minutes).
It could be wrong to assume that operating time is
correlated with postoperative discomfort, transpos-
ing such concept from general surgery to minor oral
surgery, where operating time is rarely longer than 1
hour.
Validation of the PoSSe Scale
In a recent study, Ruta et al
13
developed a postop-
erative symptom severity (PoSSe) scale specic to
extractions of third molars and assessed its validity to
measure the impact of those symptoms on patients
perceived quality of life. In our study, the clinical
validity of the PoSSe scale was provided by its ability
to discriminate between different groups of patients
and to correlate with trismus and pain objectively
measured. The pilot study of Ruta et al
13
showed a
highly signicant association between the number of
painkiller tablets taken and the PoSSe score. In this
study, we found that the PoSSe score was strongly
correlated with both trismus (r 0.54) and number
of painkillers taken (r 0.41). Consistently, trismus
gave higher correlations with the eating subscale (r
0.53) and the number of painkillers taken with pain
subscale (r 0.60). Finally, eating (r 0.83) and
interference with daily activities (r 0.71) subscales
gave higher correlations with the full PoSSe score.
According to Ogden et al,
7
patients participating in
this study felt that surgery exerted its impact on their
quality of life primarily by reducing their ability to eat
and interference with daily life. These ndings could
have important implications for the surgeon when
attending to postoperative problems and when ob-
taining informed consent.
Acknowledgment
The authors thank Dr Dario Consonni for his advice and assis-
tance regarding the statistical analyses.
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916 ASSESSING DISCOMFORT AFTER THIRD MOLAR SURGERY
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