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a
Department of Oral and Maxillofacial Surgery, Central Hospital of Tokai Medical Institute, 1, Marune,
Arao-tyou, Tokai City 476-8511, Japan
b
The Second Department of Oral and Maxillofacial Surgery, School of Dentistry, Aich-Gakuin University,
2-11, Suemori-dori, Chikusa-ku, Nagoya 464-8651, Japan
c
Department of Oral and Maxillofacial Surgery, Nagoya City Jyohoku Municipal Hospital 2-15,
Kaneda-tyou, Kita-ku, Nagoya 462-0033, Japan
Accepted 9 February 2004
predictive factors. It is more informative from a distal part of the incision to avoid accumulation of
patient’s point of view to relate outcome to factors haematoma that could result in excessive swelling.
that can be measured preoperatively than to rely For the first 3 postoperative days all patients
on an overall probability. In the present paper we were given antibiotics (amoxycillin or cefaclor
present the results of an investigation into the cor- 750 mg three times daily), drugs for peptic ul-
relation between preoperative factors (patients’ cer (ranitidine 300 mg three times daily) and an
characteristics, anatomical position of the tooth, anti-inflammatory drug (loxoprofen sodium 120 mg
and index of operative difficulty) and postoper- every 6 h). In Japan, medical insurance does not
ative morbidity (short-term outcome: pain and allow dentists to give prophylactic antibiotics.
swelling on the first day) after extraction of third The following variables were recorded before the
molars. operation:
is wider than the neck and the roots do not Health-Related Quality of Life (HRQL) instrument
separate), incomplete roots excluded) on ro- to be completed on postoperative days 1 and 7.7
tational panoramic images predicts difficulty. The amount of pain was assessed by the patients
on visual analogue scales (VAS) that ran from 0 to
The measures of outcome that we used as sur- 100 mm. The amount was arbitrarily divided into
rogate measures of morbidity (Table 2) were facial average and severe.
swelling defined by the distance from the corner of
the mouth to the ear lobe and the outer canthus of Statistical analysis
the eye to the angle of the mandible measured by
a thread which was then transferred to a ruler. Fa- The Mann—Whitney U test was used to calculate the
cial swelling was calculated as horizontal measure significance of continuous preoperative variables.
plus vertical measurement divided by 2, and per- The variables that were significant predictors were
centage of facial swelling as preoperative measure- used in a logistic regression model with facial
ment minus postoperative measurement divided by swelling, severe pain, and average pain as the de-
preoperative measurement times 100. pendent variables. In doing the logistic analysis,
These measurements and those of interincisal continuous variables and dependent variables were
opening were made on postoperative days 1 and ranked according to their median value. The post-
7 by the same person. Trismus was calculated as operative difficulty rank excluded the predictive
preoperative measurement minus postoperative model for the self-completed outcome measure-
measurement divided by preoperative measure- ment. In addition, variables with correlations of
ment multiplied by 100. In addition, each patient 0.3 or over were excluded from the model. We then
was given a questionnaire that included the revised analysed the position of the tooth (depth, relation
to ramus, and space available) and preoperative predictive of persistent severe pain were degree
index of difficulty in two models. of eruption, depth of impaction, and preoperative
Calculations were made with the statistical soft- index of difficulty (Table 2).
ware package STATISTICA 2000 (Stat Soft Inc. USA, If the three outcome factors (swelling, severe
2000). For all tests a probability of less than 0.05 pain, and average pain) were considered collec-
was considered significant. tively as a measure of morbidity then on day 1 they
were predicted by these variables: age, sex, depth,
relation to ramus, and preoperative index of diffi-
Results culty.
The independent variables that predicted
Of the 153 extractions, 54 (35%) were in male and swelling were age and sex (P < 0.04 for age and
99 (65%) in female. The median age was 27 years P = 0.04 for sex). Severe pain was significantly
(range: 17—67). The clinical indications for removal correlated with depth (P = 0.03) and preoperative
were pericoronitis in 88 (58%), pain in 17 (11%), index of difficulty (P = 0.01). Average pain was
caries in second molar in 11 (7%), orthodontic rea- significantly correlated with preoperative index of
sons in 8 (5%), impaction in 19 (12%), and request difficulty (P = 0.02).
by the patient in 10 (6%).
Univariate analysis showed that the factors that
predicted swelling on day 1 on were age, sex, and Discussion
relation to ramus (space available). Those that pre-
dicted severe pain were depth of impaction and The amount of facial swelling varied depending on
preoperative index of difficulty (Table 1). age and sex. Severe pain was associated with depth
On day 7 the factors predictive of continued of tooth and preoperative index of difficulty. Av-
swelling were age and horizontal position. Those erage pain was associated with preoperative index
of difficulty. It is quite likely that facial swelling is however, that these biases will affect the internal
affected by individual characteristics such as age validity of the main result, particularly because of
and sex. Facial swelling was also associated with the internal consistency in univariate and multi-
the relation to the ramus and space available in variate analysis. Potential problems derived from
the univariate analysis. Unlike other factors, severe somewhat arbitrary assessments of swelling and
swelling was seen with easier extractions, which pain were addressed by using univariate analysis
were associated with a wide relation to ramus and and arbitrary cut-off points, in addition to logistic
space available. We think that the relation to the regression analysis.
ramus and space available may show the form of We had few complications.1,3 There were no
the patient’s face. cases of dysaesthesia, fracture, secondary infec-
Severe pain and average pain were related to tion, or dry socket (alveolar osteitis). However, two
the depth of teeth and the difficulty of extraction. patients had subcutaneous emphysema and one ex-
Whereas swelling was more common in patients cessive bleeding. Compared with other reports, the
over 40 years of age, pain did not vary with age. postoperative complications that we encountered
The preoperative index of difficulty described by were minor.7,13,14
Yuasa et al. has been useful in predicting postop- In conclusion, we consider that the short-term
erative pain.12 outcomes of third molar operations (swelling and
Significant variables on multivariate analysis are pain) differ depending on patients’ characteristics
shown in Fig. 1 (with the exception of depth). For (age and sex) and preoperative index of difficulty.
swelling, this diagram tells us that the strengths of It would help to identify a group of patients at high
correlation of age group (40 years or over) and sex risk of severe swelling and pain and to design ran-
(male) are larger than the rest. domised trials to evaluate the effectiveness of new
We did not examine the findings on day 7 because surgical methods. For instance, subjects who have
of the small size of the effects. We did not discuss extractions should not be viewed as a uniform pop-
oral health, routine activities, overall health, and ulation when postoperative analgesia is evaluated,
other symptoms included in the HRQL report7 be- but should be stratified by operating time and pre-
cause they had little connection with swelling or operative index of difficulty. However, because of
pain. the observational nature of the study, our results
Further studies will be required to confirm the should be interpreted with caution. Further stud-
predictive factors described in this paper, and we ies of the association between preoperative find-
cannot assume causal inferences between preoper- ings and short-term outcome will help to elucidate
ative findings and outcome. We consider it unlikely, the true nature and magnitude of the association.
16 100
14 80
Worst pain (VAS)
12
10 60
Swelling
8 40
6
4 20
2
0 0
0-29 30-29 over 40 Easy Difficult
(a) (c) Preoperative difficulty index
Age (year)
16 100
14
Average pain (VAS)
80
12
10 60
Swelling
8
6 40
4 20
2
0 0
Male Female Easy Difficult
(b) Gender (d) Preoperative difficulty index
Figure 1 Box and whisker plots of significant variables: (a) swelling and age; (b) swelling and sex; (c) worst pain
and preoperative difficulty index; and (d) average pain and preoperative difficulty index. The black central symbol
indicates the median, the bars indicate the range, and the horizontal edges of the boxes the interquartile range.
214 H. Yuasa, M. Sugiura
HISTORICAL CASE
ROBERT JAMES GORLIN (1923) Gorlin is internationally known for his work in
craniofacial and deafness syndromes. He has
American oral pathologist and geneticist. Most published more than 400 articles about cran-
famous eponym: Gorlin-Goltz syndrome which iofacial syndromes, and his book Syndromes of
comprises multiple jaw cysts, cutaneous nod- the Head and Neck is the definitive work on the
ules with a propensity to malignant change, subject. This is now in its fourth edition. Gorlin
cranial enlargement and skeletal abnormali- served for 30 years as editor of the oral pathol-
ties. ogy section of Oral Surgery, Oral Medicine and
Oral Pathology. In 1997, he was presented
Robert Gorlin served in the US army during the with the Premio Anni Verdi award in Spo-
Second World War, before studying dentistry leto, Italy and was elected to the Institute of
at the University of Washington. After gradua- Medicine.
tion, he obtained an MS in chemistry. He held
a number of academic posts before he moved
to the University of Minnesota, where he be- He has given his name to many syndromes
came professor and chairman of the division and signs. One in particular is Gorlin’s sign —
of oral pathology in 1958. He became Regents’ the ability to touch the tip of the nose with
Professor Emeritus of Oral Pathology and Ge- the tongue in patients with Ehlers-Danlos syn-
netics at the University of Minnesota in 2000. drome.
He additionally served as professor of patho-
logy, dermatology, paediatrics, obstetrics, gy-
naecology and otolaryngology. He is one of 1. Gorlin R, et al. Focal facial hypoplasia syn-
the founders and a diplomate of the American drome. Acta Dermatol Venereol (Stockholm)
Board of Medical Genetics, Clinical Genetics. 1963;42:421—40.