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Purpose Carnoy's solution (CS), the gold standard for adjunctive chemical cautery in treatment of odontogenic keratocysts (OKCs), has been banned for 7 years, leading to substitution with the non-chloroform containing modified Carnoy's solution (MC) without data to support its effectiveness. We performed this study to compare the earlier data with CS to the more current outcomes with MC. Methods A retrospective cohort study was conducted on patients diagnosed with OKC and treated by a single surgeon (GHB) with enucleation and curettage (EC), peripheral ostectomy, and application of CS or MC. The primary predictor variables were use of CS or MC. The primary outcome variables were recurrence (yes vs. no) and time to recurrence. Secondary variables included demographics, anatomic location, and whether teeth adjacent to the lesion were extracted. Statistical analyses included chi-squared test/Fisher's exact test, Wilcoxon rank sum test, and Kaplan-Meier curves. Results 77 patients, 36 patients in the CS group and 41 in the MC group, met inclusion criteria, including at least 1 year of follow-up time. Characteristics of the groups were similar: median age 41.5 and 46, 61% and 71% male gender, 81% and 90% posterior, and 64% and 50% mandibular lesions, respectively. Overall recurrence was similar, 14.29%, with 5 (13.9%) recurrences in the CS group and 6 (14.6%) in the MC group (P = 0.92). Median time to recurrence was 24 months for both groups. Preserving adjacent teeth was associated with a significant increase in recurrence (P = 0.0036). Conclusion Based on this comparison of retrospective outcome data, we found no significant difference in recurrence rate or distribution of time to recurrence between OKCs treated with CS or MC. Aggressiveness of surgical technique is likely a predictive factor in recurrence rate. Future studies should focus on prospective studies and continuing follow-up of the MC group.

Summary Introduction Patients with dentofacial disharmonies (DFDs) seek orthodontic care and orthognathic surgery to address issues with mastication, esthetics, and speech. Speech distortions are seen 18 times more frequently in Class III DFD patients than the general population, with unclear causality. We hypothesize there are significant differences in spectral properties of stop (/t/ or /k/), fricative (/s/ or /ʃ/), and affricate (/tʃ/) consonants and that severity of Class III disharmony correlates with the degree of speech abnormality. Methods To understand how jaw disharmonies influence speech, orthodontic records and audio recordings were collected from Class III surgical candidates and reference subjects (n = 102 Class III, 62 controls). A speech pathologist evaluated subjects and recordings were quantitatively analysed by Spectral Moment Analysis for frequency distortions. Results A majority of Class III subjects exhibit speech distortions. A significant increase in the centroid frequency (M1) and spectral spread (M2) was seen in several consonants of Class III subjects compared to controls. Using regression analysis, correlations between Class III skeletal severity (assessed by cephalometric measures) and spectral distortion were found for /t/ and /k/ phones. Conclusions Class III DFD patients have a higher prevalence of articulation errors and significant spectral distortions in consonants relative to controls. This is the first demonstration that severity of malocclusion is quantitatively correlated with the degree of speech distortion for consonants, suggesting causation. These findings offer insight into the complex relationship between craniofacial structures and speech distortions.

Objective This study was designed to assess the number of opioid doses available to patients from filled prescriptions after adoption, in 2017, of a multimodal analgesic protocol that included opioid prescribing to manage postoperative pain. Study Design Data were retrieved from records of the first 24 patients having third molar surgery in 2017 identified from appointment schedules. Inclusion criteria were American Society of Anesthesiologists risk classification I or II, age 18 to 35 years, and at least 2 lower third molars removed. The exclusion criterion was being treated for opioid addiction/abuse. The primary outcome variable was the number of opioid doses filled by prescriptions at each patient's discretion. The primary predictor variable was the multimodal analgesic protocol. Results Data from records of 24 consecutive patients were analyzed; 83% were females. Median age was 25 years (interquartile range [IQR] 12-29 years). Median surgery time was 35 minutes (IQR 27-32 minutes). The median number of opioid doses filled in 2017 was 4 (IQR 0-4). Conclusions The outcomes from this pilot study suggest that implementation of a multimodal analgesic protocol to manage postoperative pain, while limiting the number of opioid doses available to the patient, may be an effective strategy for a wider range of patients and procedures.

Purpose To determine the prevalence of third molars in the US population and to report the differences in prevalence of visible third molars in the most recent National Health and Nutrition Examination Survey (NHANES) population of 2011 through 2012 by participant, jaw, and demographics. Materials and Methods The number of visible third molars in the NHANES data was assessed in nonclinical settings by trained, calibrated dental hygienists by decade of age beginning in the 20- to 29-year-old cohort through the 70- to 79-year-old cohort. Cross-sectional analyses of third molar data were conducted by the authors from the NHANES databases of 2001 through 2002, 2009 through 2010, and 2011 through 2012 to compare data for similarity of outcomes on third molar prevalence in the US population. Outcomes on third molar prevalence also were assessed from the NHANES of 2011 through 2012 by participant, jaw, and demographics: gender, race or ethnicity (Caucasian, African American, other), and education (less than high school, high school graduate, some college, college graduate). Results Data on the mean number of third molars from NHANES of 2001 through 2002, 2009 through 2010, and 2011 through 2012 were similar. The number of visible third molars in the NHANES of 2011 through 2012 decreased progressively from a mean of 1.48 in the 20- to 29-year-old cohort to 0.81 in the 60- to 69-year-old cohort, No visible third molars were observed in 47% of the 20- to 29-year-old cohort compared with 53% in the 50- to 59-year-old cohort. Participants who were male, non-Caucasian, and had less than a high school education were more likely to have a visible third molar in all age cohorts. No data were collected by NHANES examiners to determine why third molars were absent. Conclusion Third molar prevalence did not appear to differ in the US population during the first decade of the 21st century. Numbers of visible third molars, prevalent in young adults, decreased progressively through each successive age cohort. Demographic differences exist for prevalence of third molars in the US population.

It has been 50 years since the landmark presentation by Hugo Obwegeser at Walter Reed Army Hospital. At that conference, Professor Obwegeser offered American surgeons techniques to correct facial skeletal deformities with access through intraoral incisions. As important advances in surgical technique and anesthesia evolved for the surgical procedures, a major contribution by American orthodontists in collaboration with surgeons was the creation of a common diagnostic, planning, and treatment scheme for use by both clinician groups in the treatment of dentofacial deformities, the skeletal and dental problems of the most severely affected 5% of the population. This article summarizes what American orthodontists and surgeons have learned in the late 20th and early 21st centuries, and forecasts what might be the future of treatment for patients with dentofacial deformities.

Purpose To assess how quality of life (QoL) measures affect the decision for third molar (3M) removal in patients with mild symptoms of pericoronitis. Patients and Methods Healthy subjects, aged 18 to 35 years, with mild symptoms of pericoronitis were enrolled in an institutional review board–approved study. The demographic, clinical, and QoL data were collected at enrollment. The subjects voluntarily scheduled surgery for 3M removal. The principal outcome variable was their decision to undergo or not undergo surgery within 6 months of enrollment. The possible predictor variables in a multivariate logistic regression analysis were the demographic characteristics, dental insurance, and QoL measures. Results The mean age of the 113 subjects was 23.2 ± 3.8 years. Of the 113 subjects, 79 elected to undergo 3M removal within 6 months of enrollment (removed group) and 34 elected to retain their 3M at 6 months after enrollment (retained group). A significantly greater proportion of the removed group were white (58% vs 35%; P = .03) and reported having at least “a little trouble” with opening their mouths (38% vs 18%; P = .04) and taking part in social life (27% vs 6%; P = .01). The multivariate logistic regression model suggested the odds of electing 3M removal within 6 months of enrollment were greater for those who were white (odds ratio [OR] 2.69, 95% confidence interval [CI] 1.14 to 6.32) and those who had at least “a little trouble” with interactions in their social life (OR 3.22, 95% CI 1.08 to 9.58). Conclusions In subjects with mild pericoronitis symptoms, experiencing problems with oral function and lifestyle, factors not often considered by clinicians, were significantly associated with subjects' decision for early 3M removal.

Objective This institutional review board–approved prospective study was designed to assess the number of opioid doses available to patients from filled prescriptions (Rx) and the opioid doses taken and left over after adoption of a multimodal analgesic protocol to manage pain after surgery in 2018. Study Design The inclusion criteria were (1) American Society of Anesthesiologists risk classification I/II, (2) age 18 to 35 years, and (3) at least 2 lower third molars removed. The exclusion criterion was treatment for opioid addiction/abuse. All enrolled, consented subject-patients were treated with the multimodal analgesic protocol. In addition, subject-patients were given 2 Rx for 4 doses of hydrocodone 5 mg or acetaminophen 325 mg each: one Rx dated to be filled on the day of surgery, one Rx dated to be filled on any subsequent day; both Rx could be filled at the patient's discretion. Data were derived from an encounter form completed by the patient at surgery; a 14-day diary by the patient, which tracked opioid drugs taken; and the Rx filled as recorded in the North Carolina RxSentry Prescription Drug Monitoring Program. The primary outcome variable was the number of opioid doses filled by Rx for each subject-patient. The primary predictor variable was the multimodal analgesic protocol. Descriptive statistics were used. Results Data from 50 patients were analyzed. Of these patients, 32 (64%) were females. Median age was 22 years (interquartile range [IQR] 19–26 years). Twenty-nine (58%) subject-patients filled no Rx, 9 filled 1 Rx (18%), 12 filled 2 Rx (24%). Within the group that filled 1 Rx, 23 left-over doses out of 36 doses (64%) were not consumed. Within the group that filled 2 Rx, 36 left-over doses out of 96 doses (38%) were not consumed. Conclusions Outcomes suggest that implementation of a multimodal analgesic protocol with third molar surgery may be effective in reducing use and misuse of opioid drugs.

To assess the impact of third molar removal on the periodontal status of adjacent second molars and teeth more anterior in the mouth in patients with mild symptoms of pericoronitis.Healthy patients with mild symptoms of pericoronitis affecting at least 1 mandibular third molar were recruited for a study approved by the institutional review board. The subset analyzed in this study had all 4 third molars removed. Data were collected at enrollment and at least 3 months after surgery. Full-mouth periodontal probing was conducted at 6 sites per tooth. A probing depth of at least 4 mm (PD4+) was considered an indicator for periodontal pathology. The presence of a PD4+ on the distal of second molars (D2Ms) or anterior to the D2Ms, the number of PD4+s, and extent scores (percentage of PD4+s of all possible probing sites) were assessed at the patient and jaw levels. The association between patients' pre- and postsurgical periodontal status was assessed using the McNemar exact test. The level of significance was set at .05.The median age of the 69 patients was 21.8 years (interquartile range, 20.2 to 25.2 yr). Forty-five percent were men, and 57% were Caucasian. Significantly more patients (88%) had at least 1 D2M PD4+ at enrollment compared with after surgery (46%; P.01). D2M extent scores decreased from 31.5 at enrollment to 11 after surgery. Significantly more patients (61%) had at least 1 PD4+ anterior to the D2M at enrollment compared with after surgery (29%; P.01). Extent scores anterior to the D2M decreased from 2.0 at enrollment to 0.6 after surgery.Removal of third molars in patients with mild pericoronitis symptoms improved the periodontal status of the D2Ms and teeth more anterior in the mouth.

To assess the relationship between the presence or absence of visible third molars and outcomes for periodontal inflammatory disease.Obstetric subjects, at enrollment in an institutional review board-approved, multisite study, Maternal Oral Therapy to Reduce Obstetric Risk (N = 1,798), were divided into 2 groups, those with no visible third molars (n = 692) and those with at least 1 visible third molar (n = 1,106), the predictor variables for this study. The principal outcome variables were the patient-level periodontal status of the first/second molars: mean periodontal probing depths, mean attachment levels, and mean extent scores. Periodontal disease severity also was assessed by criteria from the Oral Conditions and Pregnancy trial and the Centers for Disease Control and Prevention/American Academy of Periodontology. Outcomes according to the presence or absence of third molars were compared with χ(2) statistics and multivariable analyses. Significance was set at P.05.Significantly more subjects had at least 1 third molar (62%) as compared with subjects with no visible third molar (38%) (P.01). Ethnic characteristics of the 2 groups were similar. Overall, more subjects were white (61%), with most identifying their ethnicity as Latino. African-American subjects were well represented (37%). Subjects with a visible third molar were more likely to be significantly older, to be receiving medical assistance, and to have used tobacco before pregnancy. If subjects had at least 1 visible third molar, the mean first/second molar probing depths, attachment levels, and scores for bleeding on probing were significantly greater even after adjustment for covariates. On the basis of either Oral Conditions and Pregnancy criteria or Centers for Disease Control and Prevention/American Academy of Periodontology criteria, subjects were significantly more likely to have moderate or severe periodontal disease if a third molar was detected.If at least 1 visible third molar was detected in subjects in the Maternal Oral Therapy to Reduce Obstetric Risk study at enrollment as compared with no detected third molars, periodontal outcomes were significantly worse.

Purpose Outcomes for peak blood levels were assessed for buffered 2% lidocaine with 1:100,000 epinephrine compared with non-buffered 2% lidocaine with 1:100,000 epinephrine. Patients and Methods In this institutional review board–approved prospective, randomized, double-blinded, crossover trial, the clinical impact of buffered 2% lidocaine with 1:100,000 epinephrine (Anutra Medical, Research Triangle Park, Cary, NC) was compared with the non-buffered drug. Venous blood samples for lidocaine were obtained 30 minutes after a mandibular nerve block with 80 mg of the buffered or unbuffered drug. Two weeks later, the same subjects were tested with the alternate drug combinations. Subjects also reported on pain on injection with a 10-point Likert-type scale and time to lower lip numbness. The explanatory variable was the drug formulation. Outcome variables were subjects' peak blood lidocaine levels, subjective responses to pain on injection, and time to lower lip numbness. Serum lidocaine levels were analyzed with liquid chromatography-mass spectrometry. Statistical analyses were performed using Proc TTEST (SAS 9.3; SAS Institute, Cary, NC), with the crossover option for a 2-period crossover design, to analyze the normally distributed outcome for pain. For non-normally distributed outcomes of blood lidocaine levels and time to lower lip numbness, an assessment of treatment difference was performed using Wilcoxon rank-sum tests with Proc NPAR1WAY (SAS 9.3). Statistical significance was set at a P value less than .05 for all outcomes. Results Forty-eight percent of subjects were women, half were Caucasian, 22% were African American, and 13% were Asian. Median age was 21 years (interquartile range [IQR], 20-22 yr), and median body weight was 147 lb (IQR, 130-170 lb). Median blood levels (44 blood samples) at 30 minutes were 1.19 μg/L per kilogram of body weight. Mean blood level differences of lidocaine for each patient were significantly lower after nerve block with the buffered drug compared with the non-buffered agent (P < .01). Mean score for pain on injection for nerve block (n = 46 scores) was 3.3 (standard deviation, 0.9). Seventy-eight percent of subjects reported lower or the same pain scores with the buffered drug; 61% of subjects reported a shorter time to lower lip numbness with the buffered drug. Conclusions Buffering 2% lidocaine with epinephrine can produce clinical outcomes favorable for subjects and clinicians without clinically detrimental peak blood lidocaine levels.

Purpose Buffering local anesthetics with epinephrine (Epi) offers clinicians options not often considered. This study assessed outcomes for pulpal anesthesia, pain on injection, and time to midface numbness for buffered 1% lidocaine with 1:100,000 Epi versus nonbuffered 2% lidocaine with 1:100,000 Epi. Materials and Methods In this trial with a randomized, crossover design, buffered 1% lidocaine was compared with nonbuffered 2% lidocaine. Subjects were adult volunteers who served as their own controls. The predictor variables were alternate drug formulations. The outcome variables were subjects’ responses to cold and electric pulp testing (EPT) stimulation of the maxillary first molar and canine, pain levels during the injection, and time to midface numbness. After maxillary field blocks with 40 mg of buffered lidocaine or 80 mg of nonbuffered lidocaine, subjects reported pain on injection and responses of the maxillary first molar and canine after cold and EPT stimulation. Teeth were tested before field block and at 30-minute intervals until a positive response was detected. Two weeks later, subjects were tested with the alternate drug combinations. For all outcome variables, assessment of treatment difference, calculated as 1% buffered minus 2% nonbuffered, was performed with the Wilcoxon rank sum test with significance at P Results More of the 24 subjects were women and Caucasian. The median age was 23.5 years (interquartile range, 21, 25 years), and the median body weight was 155 lb (interquartile range, 128.5, 176.5 lb). Pain levels during the injection were significantly lower for 1% buffered lidocaine, with P = .04. Times to response after injection were not significantly different between the 2 drug formulations for the cold test on a molar, with P = .08, or the cold test on a canine, with P = .22. However, times to response were significantly longer for nonbuffered drugs for EPT on the molar and canine, both with P = .01. Conclusions Buffering 1% lidocaine with 1:100,000 Epi reduces the pain on injection with a maxillary field block and results in similar lengths of pulpal anesthesia tested with a cold stimulus as compared with nonbuffered 2% lidocaine with 1:100,000 Epi.

Purpose To assess outcomes for pulpal anesthesia and pain on injection for buffered 1% lidocaine with 1:100,000 epinephrine (EPI) versus non-buffered 2% lidocaine with 1:100,000 EPI. Patients and Methods In a randomized cross-over trial approved by the institutional review board, buffered 1% lidocaine with 1:100,000 EPI was compared with non-buffered 2% lidocaine with 1:100,000 EPI. After mandibular nerve block with buffered lidocaine 40 mg or non-buffered lidocaine 80 mg, patients reported responses at the mandibular first molar and canine after cold and electrical pulp testing (EPT). Patients also reported pain on injection with a 10-point Likert-type scale. Teeth were tested before nerve block and at 30-minute intervals until a positive response returned. Two weeks later, patients were tested with the alternate drug combinations. The same outcomes were assessed. Predictor variables were alternate drug formulations. Outcome variables were patients' responses to cold and EPT stimulation of the mandibular first molar and canine and pain on injection. An assessment of treatment difference was performed using Wilcoxon rank-sum tests with Proc NPAR1WAY (SAS 9.3, SAS Institute, Cary, NC). Significance was set at a P value less than .05. Results Fifty-seven percent of patients were women and 43% were men. Seventy percent were Caucasian, 17% were African American, and 13% had another ethnicity. Median age was 25 years (interquartile range [IQR], 21-26 yr) and median body weight was 140 lbs (IQR, 120-155 lbs). After the cold test and EPT, the time to sensation return for the molar or canine was not statistically different between the 2 drug formulations. Patients reported significantly lower pain scores with the buffered versus non-buffered drug (P Conclusions After mandibular nerve block, buffered 1% lidocaine with EPI can produce similar clinical outcomes for duration of pulpal anesthesia as non-buffered 2% lidocaine with EPI and lower pain on injections, which are a potential benefit to patients.

Purpose The purpose of this study was to compare the prevalence of third molars from the US National Health and Nutrition Examination Survey (NHANES) and the Swedish survey. Materials and Methods This cross-sectional study involved the comparison of the only published data on third molar prevalence. The number of visible third molars in the NHANES of 2011 through 2012 were assessed in nonclinical settings by trained, calibrated dental hygienists and reported by age decade (approximately 5,000 patients). Similar data were reported for the Swedish population with data collected in clinical settings (approximately 700 patients). The primary outcome variable was the number of third molars (0 to 4); the predictor variables were age cohorts (20 to 29 through 70 to 79 yr). Outcome data were reported with descriptive statistics. Results In the youngest cohort (20 to 29 yr), having no visible third molars was more likely in the US population than in the Swedish population (47 vs 2%, respectively). By 50 to 59 years, outcomes for no third molars were similar in the United States and Sweden (53 and 57%, respectively). Conclusion The presence or absence of third molars reported from the US and Swedish populations presented contrasting patterns, particularly in the younger cohorts. More comprehensive and detailed data are required in future surveys as population studies on third molars become more important for clinicians and other stakeholders.

Purpose Compare the post-surgery red cell mass as indicated by hematocrit value of orthognathic surgery patients given iron supplementation and a single presurgery dose of erythropoietin alpha(EPO) and patients who did not receive either EPO or iron supplementation (NEPO).

Purpose To establish a relationship between visible third molars (M3s) and increased periodontal probing depths on teeth other than M3s and to examine the hypothesis that the presence of M3s and/or increased probing depths and local inflammation associated with M3s was associated with increased levels of serum inflammatory markers. Patients and Methods The data from three previous population studies (Dental Atherosclerosis Risk In Communities [DARIC], Oral Conditions and Pregnancy [OCAP], and National Health and Nutrition Estimates Study [NHANES III]) and the third molar clinical trials of young adults (White et al) are summarized. A secondary analysis determined whether the presence or absence of visible M3s was associated with an increased prevalence of clinical signs of periodontal disease using adjusted logistic regression models. In addition, serum samples collected from the OCAP, DARIC, and White studies were used to measure the markers of systemic inflammation, C-reactive protein, interleukin-6, and soluble intracellular adhesion molecule-1. Results In young adults, asymptomatic M3s were associated with an increase in periodontal probing depths of at least 4 mm on second molars and an increase in probing depth of at least 2 mm in 24% of subjects after 2 years. Retention of asymptomatic M3s for 6 years led to a significant increase in the number of subjects with a probing depth of 4 mm or more in non-M3 regions of the mouth. Findings from the DARIC, OCAP, and NHANES III further confirmed the association between the M3 probing depth and periodontal inflammation on non–M3s. Retention of M3s in the presence of periodontal inflammation was associated with significant increases in the serum interleukin-6, soluble intracellular adhesion molecule-1, and C-reactive protein levels. Conclusion Patients deciding to retain M3s should consider the potential long-term effects on their periodontal status and the potential for the retained M3s to serve as a chronic source of inflammation that stresses their systemic health.

Purpose To assess the prevalence of caries experience and periodontal pathology on third molar teeth compared with first and second molars and teeth more anterior from subjects who had data collected over time in a longitudinal clinical study. Patients and Methods Healthy subjects with 4 asymptomatic third molars and data for at least 4 years after enrollment were included in these analyses. The presence or absence of caries experience on the occlusal surface of the third molars and any surface of the first or second molars was assessed using a visual-tactile caries examination. Full mouth periodontal probing, 6 sites per tooth, was conducted as a measure of clinical periodontal status. The primary outcome measures were at least 1 periodontal probing depth of at least 4 mm versus none, and caries experience versus no caries experience. The prevalence of caries experience and periodontal pathologic findings at follow-up and the relationship of the occurrence between the third molars and teeth more anterior in the mouth were examined using McNemar's statistics. Results The follow-up was a median of 6.9 years (interquartile range 4.6 to 7.7 years) for 179 subjects, with a mean age of 29 years. More subjects were female (54%) and white (80%). At follow-up, 85% of the subjects had caries experience detected on the first or second molars, and only 50% had a third molar affected. In contrast, at follow-up, the presence of at least 1 periodontal probing depth of at least 4 mm was marginally more prevalent on the third molars than on the first or second molars (56% and 50%, respectively). Fewer subjects had third molars free of caries experience and periodontal pathology at follow-up compared with at enrollment (28% versus 38%, respectively). Conclusions The prevalence of both third molar caries experience and third molar periodontal pathology increased from baseline to the follow-up examination. At follow-up, the prevalence of caries experience was greater on the first or second molars than on the third molars, and periodontal pathology were greater on the third molars than on the more anterior teeth.

Background The authors conducted a study to examine the antibiotic prescribing practices of general and pediatric dentists in the management of odontogenic infections in children. Methods The authors relied on a cross-sectional study design to assess the antibiotic prescribing practices of general and pediatric dentists in North Carolina. The survey instrument consisted of five clinical case scenarios that included antibiotic-prescribing decisions in a self-administered questionnaire format. The participants were volunteers attending one of four continuing education courses. The authors invited all pediatric dentists in private practice to participate in the study, as well as general practitioners who treated children in general practice. The authors compared the practitioners' responses for each clinical case scenario with the prescribing guidelines of the American Academy of Pediatric Dentistry and the American Dental Association. Results A total of 154 surveys were completed and returned (55 percent response rate). The mean age of respondents was 47 years, and the mean number of years in practice was 19. Of the 154 overall, 106 (69 percent) were general practitioners and 48 (31 percent) were pediatric dentists. Across the three in-office clinical case scenarios, adherence to professional prescribing guidelines ranged from 10 to 42 percent. For the two weekend scenarios, overall adherence to the professional prescribing guidelines dropped to 14 and 17 percent. Dentists who had completed postgraduate education (n = 73 [51 percent]) were more likely ( P Conclusions The results of this survey show that dentists' adherence to professional guidelines for prescribing antibiotics for odontogenic infections in children was low. There appears to be a lack of concordance between recommended professional guidelines and the antibiotic prescribing practices of dentists. Clearer, more specific guidelines may lead to improved adherence among dentists.

Purpose To assess the impact of cryotherapy or topical minocycline on patients' perceptions of recovery from pain after third molar surgery in an exploratory comparative-effectiveness study. Patients and Methods Subjects aged at least 14 years who were having all 4 third molars removed were enrolled in 3 separate institutional review board–approved studies. Study groups included subjects treated with a passively applied cold wrap for 24 hours postoperatively, subjects treated with topical minocycline during surgery, and subjects enrolled in a nonconcurrent comparison group who had received neither topical minocycline nor directed cryotherapy. Third molar surgery was performed in all cases by trained surgeons using the same protocol. An exact Kruskal-Wallis test was used to compare the distributions of the worst and average pain scores and a Fisher exact test to compare verbal responses from Gracely pain scales among the 3 groups for postsurgical days (PSDs) 1 to 3. Results This study comprised 51 cryotherapy subjects (2005-2009), 63 minocycline subjects (2003-2004), and 92 comparison-group subjects (2002-2006) who were treated at academic centers and in community practices across the United States (N = 206). Demographic descriptors were similar among all groups. For PSDs 1 through 3 (unadjusted), the highest scores for worst pain (6-7 [out of 7] on Likert-type scale) were reported less frequently in each of the study groups than in subjects in the comparison group, although the numbers of subjects reporting the highest scores were few. The distribution of pain outcomes was significantly different among the 3 groups for worst pain and affective words on PSD 1 ( P = .04 for both). However, the small number of subjects who reported the highest pain scores precluded adequate multivariate statistical analyses for all outcomes on PSD 1 to 3. Conclusions Data from this exploratory study suggest that adjunctive therapy to decrease postoperative pain—cryotherapy or topical minocycline—might be effective at moderating the patient's highest pain levels after third molar surgery. The topic should be studied further in a multicenter, prospective, randomized trial.

Because most adolescents and young adults have at least 1 third molar, and three quarters have 4, clinicians are often faced with advising their patients about third molar management.1 The term “asymptomatic” as applied to third molars continues to be a source of confusion for those confronted with a decision on treatment. A few clinicians and the public have assumed that “asymptomatic” infers “pathology free” today and for the future. Some patients have third molars that are “symptom free and pathology free.” More often, however, third molars are “symptom free, and pathology exists,” requiring a clinical or radiographic examination for confirmation. The source of this current conundrum for clinicians and patients can be traced back at least 5 decades. In 1962, Ash et al2 cautioned that the association between third molars and periodontal pathology affecting the adjacent second molars had been overlooked. Subsequently, to preserve the periodontal health of adjacent second molars, Ash3 suggested that third molars should be removed in young adults before root formation is complete. Since then, many clinicians have heeded this advice and urged patients to have their third molars removed to prevent pathology, including periodontal inflammatory disease, from developing, although the third molar had no symptoms. Without acknowledging that only a clinical exam can confirm the absence of pathology affecting the third molars, others have questioned the wisdom of removing “asymptomatic” third molars.4

Purpose To assess the relationship between visible third molars and the periodontal status of teeth more anterior in the mouth from reports that included periodontal probing data for all teeth. Materials and Methods Each of 4 reports that included periodontal probing data, 6 probing sites for all teeth, including third molars collected by trained, clinician examiners, were briefly summarized. The design, strengths, and weaknesses of each of the 4 studies were compared and summarized. A Forest plot was used to combine the findings from the 4 studies comparing the mean second molar probing depth differences in mm by the presence of at least 1 visible third molar or no visible third molar. Results A review of the data from 4 reports, 1 from middle-age adults and 3 from young adults, suggested an association between the visible presence of a third molar and increased periodontal probing depths on teeth more anterior in the mouth, predominately the first and second molars. Coupled with the probing depth around the third molars, the result was an expanded surface area at the biofilm–gingival interface. Conclusions Although all those with retained third molars are not at increased risk, the summary data we have reported suggest that those with a visible third molar are more likely to have greater periodontal probing depths overall, particularly on second molars, and a greater surface area of the biofilm–gingival interface compared with those with no visible third molar.

Purpose To assess the prevalence of periodontal inflammatory disease on the distal side of second molars after third molar removal and the association between presurgical and surgical variables and postsurgical periodontal outcomes. Patients and Methods Data before and after surgery from 2 studies approved by an institutional review board were used. In 1 study, 26 subjects had 4 asymptomatic third molars and in the other 49 subjects had at least 1 mandibular third molar with symptoms of pericoronitis. Full-mouth periodontal probing data, 6 sites per tooth, were obtained as a measurement of periodontal status before and after surgery. A probing depth (PD) ≥4 mm on either of the 2 possible probing sites on the distal side of any second molar (D2M) served as an indicator of periodontal inflammatory disease; periodontal health was defined as all D2M PD

Purpose To assess the association between the visible presence of third molars and the severity of periodontal pathologic findings on teeth more anterior in the mouth. Patients and Methods The present analysis included dentate participants, 52 to 74 years old, from the Dental Atherosclerosis Risk in Communities study who had undergone an oral examination that included periodontal probing depths (PDs) on all visible teeth, including any third molars. A PD of 4 mm or more and a clinical attachment level of 3 mm or greater were indicator variables for periodontal pathologic features. Explanatory variables were the presence or absence of visible third molars. The covariates included gender, ethnicity, age, income level, education, and smoking status. The outcome variables for periodontal pathologic features were the mean PD, extent (percentage of probing sites) of PDs of 4 mm or more, and the extent (percentage of probing sites) of a clinical attachment level of 3 mm or more. The outcomes between those with and without visible third molars were compared using descriptive statistics and chi-square tests, with significance set at P = .05. Multivariate modeling was performed using Statistical Analysis Systems SAS Proc GLM (SAS Institute, Cary, NC) to calculate the least squared means, adjusting for the study outcome variables and covariates. Results The Dental Atherosclerosis Risk in Communities study sample included 6,793 subjects; 80% were white and 19% were black. Most (53%) were 62 to 74 years old and female (54%). Of the 6,793 participants, 2,035 (30%) had at least 1 visible third molar. The presence of a visible third molar was significantly associated with male gender, black race, age younger than the mean of 62.4 years, greater income, and never smoking (all P < .01). A greater mean PD for the first and second molars, the extent of PD of 4 mm or more at the first and second molars, and the extent of a clinical attachment level of 3 mm or more at the first and second molars were all significantly associated with the presence of a visible third molar in the unadjusted and adjusted models. Conclusions In these middle-age and older Americans, the presence of a visible third molar was significantly associated with more severe periodontal disease on teeth more anterior in the mouth compared with those subjects with no visible third molars.

The American Association of Oral and Maxillofacial Surgeons (AAOMS) has been at the forefront of formal evidence-based dentistry with such projects as the Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgeons, the AAOMS Outcomes Assessment Program, the AAOMS Third Molar Clinical Trial, and the AAOMS "White Paper on Third Molar Data." This article reviews these evidence-based resources to provide a consensus of opinion for the management of the third molar.

To compare the prevalence and severity of periodontal inflammatory disease in subjects with pericoronitis involving a mandibular third molar and those without pericoronitis.Data obtained from healthy adults consecutively enrolled in an institutional review board-approved trial with pericoronitis affecting at least 1 mandibular third molar (study group) were compared with data obtained during the same time frame from subjects without pericoronitis enrolled in a longitudinal third molar monitoring study (comparison group). The periodontal status of each subject was classified based on periodontal probing depths (PD): all PD4 mm, no disease; 1 to 3 PDor=4 mm, incipient disease; at least 4 PDor=4 mm, early disease. Full mouth periodontal probing data were obtained as clinical measures of periodontal status. Data were aggregated to the subject level for the third molar region, the 6 third molar probing sites and the 2 second molar distal probing sites, the non-third molar region, and all remaining probing sites. The prevalence of disease in the study and comparison groups were compared with the Fisher's exact test. As an indicator of disease severity, the number of PDor=4 mm in the 2 groups were compared by the Kruskal-Wallis test. Level of significance was set at P values less than .05.Median age of the 56 subjects with pericoronitis was 23.3 years (IQR 21.3-26.0 years). Fifty-five percent were Caucasian, 16% African American, and 22% Asian. Males and females were almost equally represented in the study group and in the comparison group. The 194 subjects enrolled without pericoronitis were significantly older (32.8 years; IQR 27.2-40.0 years; P.001). Eighty-four percent were Caucasian, 10% African American, and 4% Asian. The proportion of subjects with periodontal inflammatory disease in the third molar region was significantly different between the study and comparison groups. Thirty-one percent of the subjects with pericoronitis had incipient and 55% early disease in the third molar region compared with 25% with incipient and 38% with early disease among subjects without pericoronitis (P = .003). The pattern was similar, but the proportion of subjects was not significantly different between the groups for the non-third molar region. In the study group, 32% had incipient disease and 32% early disease compared with 27% with incipient disease and 22% with early disease in the comparison group (P = .09). The median number of PDor=4 mm for all teeth differed significantly for subjects with and without pericoronitis (median 5 [IQR 3-9] vs 3 [IQR 0-8], respectively; P = .03).Pericoronitis involving mandibular third molars may reflect more underlying periodontal inflammatory disease in affected young adults than might be found in young adults with retained third molars and no pericoronitis.

Purpose To assess the impact of mechanical debridement (scaling and root planing), without adjunctive therapy, on reducing the numbers of periodontal pathogens detected in pregnant subjects with and without visible third molars. Patients and Methods Sixty-seven subjects in the second trimester of pregnancy were enrolled in an institutional review board-approved study. Full mouth periodontal exams of all teeth were conducted at baseline and postpartum. Presence or absence of third molars was noted. Subgingival biofilm samples were obtained from the mesiobuccal of all first molars at enrollment and postpartum. Subjects' total counts for periodontal pathogens in biofilm samples were determined by DNA-DNA checkerboard hybridization. We analyzed data from a subsample of 26 subjects. All subjects in the study were treated at enrollment by mechanical debridement of all teeth, including third molars. Differences between subjects' baseline and postpartum demographic and clinical characteristics were analyzed by χ2 and t tests by presence or absence of third molars. Statistical significance for differences in pathogen levels was determined by Rank analysis of covariance. Significance was set at 0.05 without correction for multiple comparisons. Results Most of the 26 subjects were African American (61%), on Medicaid (92%), and did not smoke during pregnancy (88%). The 15 subjects with visible third molars were significantly older (28.0 years [SD 6.4] vs 23.7 years [SD 3.9]). In the 11 subjects with no third molars noted, all pathogen counts were reduced postpartum. In the 15 subjects with visible third molars, total counts for each pathogen analyzed were higher postpartum as compared with subjects with no visible third molars, and their bacterial counts were increased for 5 of the 8 pathogens, including all “red cluster” pathogens. Differences between study groups were observed by the presence or absence of third molars for T. forsythia and P. nigrescens (P = .04), and for P. gingivalis, F. nucleatum, total “orange cluster” bacteria, and total pathogens (P Conclusion The efficacy of mechanical debridement to lower periodontal pathogen counts during pregnancy was limited by the presence of visible third molars and should be analyzed further in larger scale trials.

The purpose of this study was to assess changes in periodontal probing depth (PD) over time for third molar and nonthird molar regions in young adults.The data were obtained from healthy subjects with 4 asymptomatic third molars, enrolled in an IRB-approved longitudinal trial. Demographic and oral health data were collected at baseline. Full-mouth PD, 6 sites per tooth, was conducted to determine periodontal status at baseline and at longest follow-up. The third molar region was defined as the PD for 6 sites around the third molars and the 2 sites on the distal of the second molars. The nonthird molar region was defined as the remainder of the PD sites in the mouth. The primary outcome measures for this study were the occurrence of a PD greater than or equal to 4 mm and the increase in PD of at least 2 mm in the third molar and nonthird molar regions. Changes from enrollment to longest follow-up were compared by the binomial or McNemar's test. Level of significance was .05.Data from 195 subjects were available, and the median follow-up was 5.9 years (interquartile range [IQ], 4.6 to 6.9 years). Median age at enrollment was 26.2 years (IQ, 22.0 to 34.0 years); 52% were female, 84% were Caucasian, and 10% were African American. The proportion of subjects with at least 1 involved site in nonthird molars increased significantly from baseline to follow-up, 36% to 49% (P.01), reflecting mostly changes in mandibular nonthird molars, 33% to 48% (P.01). Of the 122 subjects who presented at baseline with at least 1 PD greater than or equal to 4 mm in the third molar region, the proportion of subjects with at least 1 involved site in nonthird molars increased significantly from baseline to follow-up, 48% to 59% (P = .05), also reflecting mostly changes in mandibular nonthird molars, 44% to 59% (P = .05).In this unique longitudinal clinical study of early periodontal disease in young adults, periodontal pathology worsened over time for nonthird molars. This was more likely if PD greater than or equal to 4 mm was detected in the third molar region.

This study was designed to identify risk indicators for the prevalence at enrollment and incidence over 36 months of periodontal pathology and coronal caries experience affecting third molars in a community-based study of people over 65 years of age.Data from a subsample of 810 dentate subjects from the Piedmont 65+ Study were available for analyses. All visible teeth were examined. Periodontal probing measures were taken at 2 sites, mesiobuccal and buccal/facial. Clinical data on caries experience were collected by visual-tactile examination. At enrollment, 340 subjects had at least 1 visible third molar; all were examined for caries experience. Periodontal probing measures were available for 277 of these same subjects. The significance of the possible risk indicators for periodontal pathology and caries affecting third molars was determined by chi(2) tests. Statistical significance was set at .05. Logistic multivariable models were used to derive odds ratios and 95% confidence intervals.African-American subjects were more likely to have visible third molars (P.01). Caucasian subjects were more likely to have third molar coronal caries experience (P.01), as were subjects with greater than a high school education and those with a dental visit within 3 years (both P.01). However, African American subjects were more likely to have periodontal pathology, CALs/= 3 mm on third molars (P.01), as were those who used tobacco (P.01). None of the other risk indicators we studied were associated with progression of periodontal pathology or coronal caries experience on visible third molars.In this population study of senior adults, Caucasians and African Americans appear to have different levels of risk for caries experience and periodontal pathology affecting retained third molars.

This study was conducted to determine if the completeness of the root formation of mandibular third molars prior to removal affected clinical and health-related quality of life (HRQOL) recovery.Data from HRQOL responses from patients and clinical outcome data were available after third molar surgery conducted by surgeons in community practice and academic centers. The root development of each mandibular third molar on presurgery panoramic radiographs for these patients was assessed by trained clinician observers. Patients were categorized as those with complete root formation (both mandibular third molars had 100% completely formed roots) or as those with incomplete root formation (at least 1 mandibular third molar not completely formed). The proportion of patients who experienced delayed clinical or HRQOL recovery that exceeded a clinically relevant criterion value were compared for these 2 groups of patients using chi2 statistics. Level of significance was set at 0.05.Both mandibular third molars had 100% completely formed roots in 118 patients; at least 1 mandibular third molar was not completely formed in 218 patients. If patients had a mandibular third molar with roots less than 100% complete, they more likely: were female (65% vs 58%), were less than 25 years old (95% vs 54%), P.01, and had not finished high school (59% vs 28%), P.01. For those with incomplete root formation, bone removal for both mandibular third molars was more likely (84% vs 67%), P.01, and the surgeons' overall estimate of degree of difficulty was greater (14/28 vs 12/28), P = .02. Median surgery time did not differ between groups. The proportion of patients who experienced delayed clinical or HRQOL recovery did not differ between the incomplete and complete root formation groups.Incomplete lower third molar root formation presurgery may not be a predictor of better or worse clinical or HRQOL recovery after surgery. Other clinical, demographic, and health indicators should influence surgeons' recommendations and patients' decisions regarding third molar treatment including surgery.

Third Molar Clinical Trials is a targeted research project with a goal of providing current clinical and biological data to support effective third molar treatment. This special contribution, modified from the report on the progress of Third Molar Clinical Trials to the American Association of Oral and Maxillofacial Surgeons House of Delegates in 2006, summarizes progress on this complex project spanning almost a decade. An annotated bibliography of peer-reviewed publications to date is included.

This study was designed to assess the prevalence at enrollment and incidence over 36 months of periodontal pathology and caries affecting third molars in a community-based study of people over the age of 65 years in North Carolina.A sub-sample of 818 subjects with dental examinations taken from the Piedmont 65+ Study was available for analysis. All visible teeth were examined. Periodontal probing (PD) measures were taken at 2 sites, mesiobuccal and buccal/facial. Clinical data on caries experience were collected by visual-tactile examination. At enrollment, 342 subjects had at least 1 visible third molar that could be examined. PD measures were available for 276 of these same subjects. The significance of comparisons between third molars and nonthird molars were determined by chi(2) tests and the statistical significance was set at .05.Most of the 342 subjects with at least 1 visible third molar were female (57%) or African American (63%). Mean age was 73 years (SD 5.5 years). Of the 197 subjects with caries experience, third molars were affected in 49% of subjects, less than the 87% in nonthird molars. Third molar caries experience was associated with caries experience on nonthird molar teeth (P.01). Clinical attachment level (CAL) greater than 3 mm was detected at enrollment in third molars in 68% of subjects, and in nonthird molars in 96%. With one exception, CAL greater than 3 mm in third molars was associated with CAL greater than 3 mm elsewhere in the mouth. Few subjects (17%) had clinical evidence of both caries and periodontal pathology affecting third molars. In this older population of individuals with third molars, 21% were free of periodontal pathology or caries experience.Data on the prevalence of third molar periodontal pathology and third molar caries experience in an elderly population should be useful to both clinicians and their younger patients when considering the merits of retaining or removing third molars with no evidence of pathology.

Purpose To provide clinicians with an annotated bibliography of published articles from research funded externally by the Oral and Maxillofacial Surgery Foundation, spanning 1996 to 2015, addressing the topic of third molar management. Materials and Methods A brief summary for each article was generated by the respective authors. Results The complete annotated bibliography generated by the authors is included in the Appendix. Conclusion The annotated bibliography provides clinicians and other interested individuals with a summary of current literature emanating from clinical studies on third molar topics.

Purpose This study was designed to further our understanding of recovery after third molar surgery by using 2 instruments to measure quality of life outcomes, the more global Oral Health Impact Profile (OHIP-14), and the condition-specific Health-Related Quality of Life (HRQOL) instrument. Patients and Methods Clinical and quality of life data pre- and postsurgery from 63 patients with all 4 third molars below the occlusal plane, treated with topical minocycline during third molar surgery to reduce the incidence of delayed clinical healing, were available for analyses. Each patient was given 2 questionnaires to complete; the more global OHIP-14 and the HRQOL instrument designed to assess recovery after third molar surgery. Prevalence, Extent, and Severity of the OHIP-14 scores were calculated presurgery and for postsurgery days (PSD) 1, 7, 14. The percentage of patients reporting clinically relevant responses detrimental to quality of life from the condition-specific HRQOL instrument were reported for the same time frame. Results Study patients were most likely female, less than 25 years old, and Caucasian. Most (72%) had bone removed from both lower third molars. Median surgery time was 27 minutes (interquartile range [IQ], 20, 40 minutes.). Median surgeons’ estimate of overall difficulty was 14 of a possible 28 (IQ 10, 18), and the median degree of difficulty for lower third molars was 8 of 14 (IQ 6, 10). Few patients (only 10%) had delayed clinical healing. Prevalence for all OHIP-14 items, percent of patients reporting items “fairly often” or “very often,” were increased from presurgery on PSD 1 and then decreased on PSD 7 and PSD 14. OHIP-14 Severity scores, the sum of OHIP-14 responses, followed the same pattern as the Prevalence scores. OHIP-14 Severity scores on PSD 1 were 27 (IQ 16, 34), decreasing to 8 (IQ 3, 13) by PSD 7, and 1 (IQ 0, 5) by PSD 14. Recovery for outcomes addressed by both instruments followed a similar pattern and time course. However, each instrument also assessed distinctly different outcomes, adding information that could not be obtained by 1 instrument alone. Conclusion Complementary instruments to measure quality of life outcomes provide a broader understanding of recovery after third molar surgery.

Purpose: To assess the association between risk markers of chronic oral inflammation and changes over time in periodontal probing depth (PD) in the third molar region, the distal of a second molar, or around a third molar. Subjects and Methods: The data from these analyses are part of a study of subjects enrolled with 4 asymptomatic third molars with adjacent second molars in an institutional review board-approved longitudinal trial. Full-mouth periodontal probing was conducted at enrollment and follow-up. Enrollment levels of periodontal pathogens and gingival crevicular fluid inflammatory mediators were assayed as indicators of the degree of oral inflammation. Subjects were categorized as those who had at least a 2 mm change in periodontal PD between baseline and follow-up in the third molar region and those who did not. The relationship between aggregated subject baseline PD, levels of periodontal pathogens, and gingival crevicular fluid IL-1β, and the proportion of subjects with changes in PD ≥2 mm versus those with PD

Purpose This study was designed to assess changes in third molar position and angulation in young adults and the resulting third molar periodontal probing (PD) status. Patients and Methods Data derived from patients with 4 asymptomatic third molars with adjacent second molars enrolled in an institutional review board approved longitudinal trial. Inclusion criteria for the trial dictated that patients be healthy and 14 to 45 years of age. Panoramic radiographs were analyzed for third molar angulation as compared with the long axis of the second molar (mesial/horizontal ≥25°) and eruption to the occlusal plane. Full mouth PD including third molars was conducted at follow-up. At follow-up, PD ≥4 mm distal of second molars or around third molars was considered important clinically. Results Data from 237 patients were available. Median age was 25.9 years (interquartile range [IQ], 22.1 years, 32.8 years). With a median follow-up of 2.2 years (IQ, 2.0 years, 3.7 years), 44% of impacted maxillary third and 26% of impacted mandibular third molars changed angulation or position. One third of vertical/distal impacted third molars in both jaws and 11% mesial/horizontal mandibular third molars erupted to the occlusal plane during follow-up from baseline. If mandibular third molar angulation as compared with the long axis of the second molar was mesial/horizontal ≥35°, only 3% erupted to the occlusal plane. At follow-up, 11% of the 125 impacted maxillary third and 29% of the 133 impacted mandibular third molars had PD ≥4 mm. Similarly, 11% of the 307 maxillary third molars at the occlusal plane had PD ≥4 mm, but 51% of the 312 erupted mandibular third molars were affected. Conclusion A change in third molar position or angulation was common. Erupted mandibular third molars were more likely to have PD ≥4 mm.

Purpose This study was designed to assess the impact of taking pain medications, as a more comprehensive indicator of perceived pain, on the extent of interference with lifestyle and oral function during recovery after third molar surgery. Patients and Methods Recovery data after the removal of 4 third molars were available for patients enrolled in an institutional review board-approved, prospective, multicenter clinical trial. A self-administered health-related quality of life instrument, designed to assess a patients perception of recovery for pain, lifestyle, and oral function, was completed each postsurgery day (PSD) for 14 days. Taking pain medications was a proxy for a patients perceived level of pain, adding a more sensitive behavioral component to the report of pain. Each PSD day, the patients who thought that their pain was sufficient to require taking medications (an opioid, a nonsteroidal anti-inflammatory, or the combination) were compared with patients not taking pain medications. The extent of interference in lifestyle (daily activity, social life, recreation, sleep) and in oral function (eating, chewing, mouth opening) as self-reported on a scale of 1 (no trouble) to 5 (lots of trouble) were compared for those taking and not taking medications using Cochran-Mantel-Haenszel row mean statistics ( P < .05). Results The 445 study patients were mostly female (63%) and white (86%). Median age was 20 years (IQ, 18, 24 years). Median surgery time was 30 minutes (IQ, 20, 40 minutes). Both mandibular third molars were below the occlusal plane in 60%. Almost all patients took pain medication on PSD 1. By PSD 7, 48% of patients were taking pain medication, decreasing to 20% by PSD 11. Patients with pain sufficient to take an analgesic reported a greater extent of interference for all lifestyle and oral function measures. Recovery was significantly delayed for PSD 2 through 14 for patients who took medications ( P < 0.01). Recovery for females taking pain medications was significantly delayed compared with that for males. Conclusions Patients with pain sufficient to prompt taking pain medications were likely to report interference with recovery for lifestyle and oral function. A patients choice to take pain medication appears to be a better indicator of a patients perceived pain and the impact of that pain on recovery than numerical pain scales. This method provides more sensitive behavioral information during the period of recovery after third molar removal.

Purpose This study was designed to examine the impact of delayed clinical healing after third molar surgery on health-related quality-of-life recovery (HRQOL). Patients and Methods Recovery data after removal of 4 third molars for patients in an institutional review board-approved, prospective, multi-site, clinical trial were analyzed. Data obtained from patients with a HRQOL instrument, which included domains for lifestyle, oral function, and pain items, assessed recovery for each of 14 days postsurgery. Delayed clinical healing was defined as having at least 1 postsurgery visit with treatment. Prevalence ratios (PR) with 95% confidence intervals were calculated to compare the prevalence of delayed HRQOL recovery between those participants with delayed clinical healing and those without. Sensory intensity and unpleasantness scores from Gracely scale data for each postsurgery day were compared for those patients with and those without delayed clinical healing using the Cochran-Mantel-Haenszel row mean score statistics. The level of significance was set at .05. Results Recovery data were analyzed for 547 patients. A subset of the patients also completed Gracely scales each day. If a patient had delayed clinical healing, the prevalence of delayed recovery for lifestyle nearly doubled (prevalence ratio (PR), 1.7; 95% CI, 1.3 to 2.3). Similarly, a higher proportion of those with delayed clinical healing also reported delayed oral function recovery (PR, 1.8; 95% CI, 1.4 to 2.3); late symptoms recovery (PR, 2.0; 95% CI, 1.2 to 3.6) and delayed resolution of pain (PR, 1.6; 95% CI, 1.3 to 2.0). Statistically significant average differences existed between those with delayed clinical healing and those without for the sensory intensity of pain and the unpleasantness of pain from postsurgery day 3 through day 14 ( P ≤ .01). Conclusion Delayed clinical healing after third molar surgery significantly increased the prevalence of delayed recovery for lifestyle, oral function, late symptoms, and pain.

Purpose We sought to determine the incidence of caries experience on the occlusal surface of asymptomatic third molars erupted to the occlusal plane and to examine the association between the prevalence of caries experience in third molars and other molars. Patients and methods Clinical data were collected from healthy patients (ASA Class I, II) with asymptomatic third molars enrolled at 2 clinical centers in an institutional review board-approved clinical trial. All patients with at least one third molar at the occlusal plane and with data at baseline and from the most recent of at least 2 follow-up visits were compared in the analysis. At each visit, the presence or absence of caries experience on the occlusal surface of third molars and on any surface of the first and second molars was recorded during clinical and radiographic examinations. Results Median time between baseline and the most recent follow-up examination was 2.9 years (interquartile range, 1.6 to 4.0 years). Patients (N = 211) were more often female (55%) and white (79%). Median age at baseline was 26.6 years (interquartile range, 22.7 to 32.6 years). At baseline, 29% of patients were affected by third molar occlusal caries, increasing to 33% at follow-up. Older patients at baseline had more caries in a third molar than those younger than 25 years (43% versus 9%). However, patients who were younger at baseline were more likely to develop caries in third molars at follow-up (9% versus 19%). Mandibular third molars were affected more often than maxillary third molars: 25% versus 19% at baseline and 29% versus 22% at follow-up. At baseline and at follow-up, nearly all patients with third molar caries, 98% and 99%, also had caries in first/second molars. Conclusions The 3-year caries incidence in third molars erupted to the occlusal plane was highest among younger patients and mandibular teeth. The presence of caries in first/second molars at baseline was highly predictive of the development of third molar caries during the ensuing 3 years.

Purpose The study goal was to assess the association between the presence of visible third molars and periodontal pathology in a community-dwelling sample of middle-aged and older adults. Materials and methods Data were obtained between 1996 and 1999 on 6,793 persons aged 52 to 74 from the Dental ARIC Study, a substudy of the Atherosclerosis Risk in Communities Study. The main independent variable was presence or absence of third molars assessed visually, and the dependent variable was assessment of periodontal disease as measured by pocket depth of 5 mm or greater (PD5+). Periodontal measures included pocket depth, gingival recession, and attachment level on 6 sites per tooth on all remaining teeth. Second molars were compared for periodontal pathology based on the presence or absence of a visible third molar in the same quadrant. Associations were determined using odds ratios and 95% confidence intervals. Weighted multivariable models were fit using logistic regression, and variances were adjusted to account for the clustering of quadrants within persons with the use of SUDAAN (Research Triangle Institute, Research Triangle Park, NC). Results A visible third molar was associated with 1.5 times the odds of PD5+ on the adjacent second molar, while controlling for other factors associated with the presence of third molars and periodontal disease. Other factors positively associated with PD5+ in the model were male gender, older age, smoking, and irregular and episodic dental visits. Conclusions The finding of more severe periodontal conditions associated with visible third molars in these middle-aged and older adults indicates that third molars may continue to have a negative impact on periodontal health well into later life. The relationship between third molars and periodontal disease pathogenesis deserves further study using longitudinal data.

Purpose This study was designed to assess the impact of “pain and swelling” associated with third molars on patients’ quality of life before surgery. Patients and Methods The data for these analyses were obtained from a larger ongoing study designed to examine the surgical and medical management of problems associated with third molars. Data from 480 patients with 4 third molars scheduled for removal were used in the analysis. Questionnaires administered presurgery assessed patients’ medical and dental history, their reasons for seeking third molar removal, and sociodemographic characteristics. Adverse impacts on oral health-related quality of life were measured using the 14-item Oral Health Impact Profile (OHIP) questionnaire. The primary outcome variable was the percentage of people reporting 1 or more of the 12 non-pain-specific OHIP items “fairly often” or “very often” during the 3 months before enrollment. Results One third (178 of 480) of patients said they were seeking third molar surgery because of current or previous symptoms of pain/swelling, and 17% reported 1 or more of the 12 non-pain-specific OHIP items. In the multivariate logistic regression model, the odds of one or more impacts was greater for people who presented because of symptoms (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.7 to 4.8), who were aged 25 years or more (OR, 1.9; 95% CI, 1.1-3.3), and who had a self-reported history of tooth loss due to pathology or trauma (OR, 2.9; 95% CI, 1.9 to 5.5). Conclusions Adverse impacts on quality of life occurred for 1 in 8 patients seeking third molar surgery, and the odds increased 3-fold for patients who had experienced pain/swelling compared with those who were asymptomatic.

Our goals were to determine the prevalence of caries experience, carious lesions, or restorations on the occlusal surface, in asymptomatic third molars erupted to the occlusal plane, and to examine the association between caries experience in other molars and third molars within the same mouth and quadrant.Clinical data assessing oral health were collected from healthy patients (ASA I, II). The presence or absence of caries experience on the occlusal surface of third molars and on any surface of the first and second molars was recorded during clinical and radiographic examinations. The occurrence of caries experience for younger and older subjects was compared using the general association Cochran-Mantel-Haenszel statistic and the association of occurrence in the maxilla and mandible by the McNemar test. The association between caries experience in a third molar and caries experience in first and second molars also was assessed.Overall, 28% of the 303 patients with at least 1 third molar at the occlusal plane were affected by third molar caries. Patients 25 years or older had more caries experience in a third molar than those younger than 25 years, 39% versus 11% (P.0001). Mandibular third molars were affected more often than maxillary third molars, 24% versus 18% (P.0001). Nearly all patients, 76 of 80 (95%), with third molar caries experience also had caries experience in first/second molars, but only 80 of 223 (36%) of patients with first/second molar caries experience had a history of third molar caries.The prevalence of caries in third molars erupted to the occlusal plane in these young patients was high, but not unique to third molars, particularly in those 25 years of age and older. Although these results provide a baseline description of the association between caries experience in first/second molars and associated third molars, data are needed from longitudinal studies to determine the value of first/second molar caries experience in predicting the risk of caries in third molars.

Purpose: We sought to compare recovery for clinical and health-related quality of life (HRQOL) outcomes after third molar surgery in patients treated with or without intravenous antibiotics at surgery. Patients and Methods: Fifty-six patients at least 18 years of age and with all 4 third molars below the occlusal plane, treated at 3 clinical centers, were given intravenous antibiotics just before third molar surgery. Clinical and HRQOL outcomes of these patients were compared with those of a nonconcurrent control group (n = 60 patients) who did not receive antibiotics. The control group was selected using the same criteria and treated under the same surgical protocol as the antibiotic group. Differences between the groups were assessed with Cochran-Mantel-Haenszel row mean score statistics. Results: The incidence of delayed clinical recovery defined as a postsurgery visit with treatment was higher in the control group compared with the antibiotic group. In the antibiotic group, 4% had 1 postsurgery visit with treatment; no patient had 2 visits. In the control group without antibiotics, 28% had at least 1 postsurgery visit with treatment (P < .0001) and 13% had at least 2 postsurgery visits with treatment. No statistically significant differences in HRQOL outcomes were found between the 2 groups. Conclusions: Administration of intravenous antibiotics before third molar surgery may improve clinical recovery in healthy adult patients with all 4 third molars below the occlusal plane, a presenting characteristic that has been suggested as a risk factor for delayed recovery. The findings from this exploratory trial indicate that evaluation of the effectiveness of systemic antibiotic administration with third molar surgery in a randomized, multi-intervention, explanatory clinical trial is warranted.

Purpose: Our goal was to report the detection and levels of pathogenic bacteria in subgingival plaque samples taken from the distal of all second molars in 295 patients with asymptomatic third molars. Patients and Methods: Data assessing oral health were collected from each of these healthy patients (ASA Classes I and II). Probing depth (PD), at 6 sites per tooth, including third molars, was obtained to determine periodontal status. Subgingival plaque samples were taken from the distal of all second molars before periodontal probing. The presence and levels of 11 bacterial species were determined using whole chromosomal DNA probes and checkerboard DNA-DNA hybridization. Detected bacterial species were grouped into clusters of periodontal pathogens designated as “red” or “orange” complex microorganisms as described by Socransky et al (J Clin Periodontal 25:134, 1998) who found an association of these specific microorganisms with periodontitis. Results: As a group these relatively young patients were periodontally healthy. “Orange and red” complex microorganisms were detected at levels equal to or greater than 105 more often if patients had a PD equal to or greater than 5 mm with periodontal attachment loss at the distal of second molars or around third molars at their entry examination. In patients with no PD equal to or greater than 5 mm in the third molar region, “orange and red” complex microorganisms were detected at levels equal to or greater than 105 more frequently than would be anticipated in patients with little clinical evidence of periodontal disease. Conclusions: The clinical findings of increased periodontal PDs and periodontal attachment loss coupled with colonization of periodontal pathogens support the concept that clinical and microbial changes associated with the initiation of periodontitis may present first in the third molar region in young adults. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:1234-1240, 2002

Purpose: We report the prevalence of periodontal probing depth (PD) as a clinical measure of the extent of periodontitis associated with asymptomatic third molars at the initial examination in a cohort of patients enrolled in an institutional review board–approved longitudinal clinical trial. Patients and Methods: Three hundred twenty-nine healthy patients were enrolled during a 30-month period. Full mouth periodontal probing that included third molars was conducted to determine periodontal status. Panoramic radiographs were taken to assess the degree of eruption of the third molars and the angulation of third molars compared with the adjacent second molar. Vertical bitewing radiographs were analyzed to detect alveolar bone levels relative to the cementoenamel junction on the distal of second molars. Results: Twenty-five percent (82 of 329) of all enrolled patients, and 34% (14 of 41) of black patients, had at least one PD equal to or greater than 5 mm on the distal of a second molar or around a third molar. PD equal to or greater than 5 mm was associated with periodontal attachment loss of at least 1 mm in every patient; PD equal to or greater than 5 mm was associated with attachment loss equal to or greater than 2 mm in 80 of 82 patients. A higher proportion of patients 25 years old or older had a PD equal to or greater than 5 mm on the distal of second molars or around third molars compared with patients younger than 25 years (33% vs 17%, P =.002). The distals of second molars and third molars in the mandible were affected more often than in the maxilla (25% vs 5%, P =.0001). Conclusions: Our data indicating that 25% of patients with retained asymptomatic third molars have considerable periodontal pathology in the third molar region were unexpected. National epidemiologic surveys indicate a much lower rate of periodontitis in the population younger than 35 years. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:1227-1233, 2002

Purpose: Vastly different surgical techniques have been advocated for osseous reconstruction of the severely atrophic mandible. Endoseous implants placed in autologous bone grafts have been proposed to minimize graft resorption and restore function; however, sufficient bone must exist to support the implants and prevent pathologic fracture. The purpose of this retrospective analysis was to assess the efficacy of autologous bone grafting and the subsequent placement of endosteal implants as a staged procedure in patients with severely atrophic mandibles. Materials and Methods: The records of all patients presenting to The University of North Carolina for treatment from 1997 to 1999 with atrophic mandibles (vertical mandibular height

Although orthognathic surgery was done earlier, the surgeon-orthodontist interaction really began to develop after introduction of the sagittal split osteotomy in the 1950s. This was facilitated by the demonstration that rectangular orthodontic archwires in edgewise brackets were quite satisfactory for surgical patients, so that both pre- and post-surgical orthodontics could be used routinely without changing the orthodontic appliance. The interaction was accentuated as cephalometric prediction of surgical treatment became an important part of treatment planning, and as the LeFort I osteotomy made it possible to reposition the maxilla as well as the mandible. Careful study of the outcomes of varying surgical approaches and orthodontic techniques, made possible by long-term support by the National Institute of Dental and Craniofacial Research, has paid off by allowing surgeons and orthodontists jointly to choose the most successful procedures.