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ORIGINAL ARTICLE
in humans1. The prevalence of impacted mandibu- development of distal cervical caries in the adjacent
lar third molars varies widely in the literature due second molar teeth4.
to differences in the age of populations studied, The British Association of Oral Surgeons repre-
failure to distinguish between one or multiple sents one of the main workforces providing M3M
impacted third molars, and pre- and post-surgery surgery in the UK. The aim of this survey was to
cohorts2. However, surgical removal of M3Ms is evaluate current practice within BAOS membership
one of the most commonly performed outpatient of pre-operative planning, consent, surgical tech-
procedures in the UK National Health Service1. niques and post-operative nerve injury rates in M3M
M3M surgery in the UK is provided by diverse surgery against current evidence and relevant guide-
services and practitioners, ranging from primary lines.
care dental surgeons to consultant-led oral surgery
services in district general hospitals and dental
Methods
teaching hospitals.
An impacted tooth is defined as one whose erup- The survey was written using the web-based Survey
tion is impeded by a lack of sufficient space in the Monkey (Palo Alto, CA, USA) platform and con-
arch, ectopic position of the developing tooth germ, tained 20 questions. These were extensively piloted
or presence of an obstruction such as a supernumer- with a group of 12 senior oral surgeons who pro-
ary tooth, retained deciduous tooth, tumour, cyst or vided feedback and suggestions for improvement.
scar tissue3. The mandibular third molar is the most The final survey was emailed to all 520 members of
commonly impacted tooth in the arch. The presence BAOS in March 2015 with a reminder email sent
of an impacted M3M can lead to difficulty in main- 2 weeks later. The survey was closed to respondents
taining oral hygiene, periodontal inflammation and in June 2015. The data were then analysed using
pericoronitis, dental caries in the third molar, distal Microsoft Excel (Redmond, WA, USA).
cervical caries in the second molar and less com-
monly cyst or tumour development4. Surgical
Results
removal of M3Ms, where indicated, will alleviate
symptoms of pain and swelling to restore oral health Of the BAOS membership (n = 520), 250 responded
and normal function5. Frequent post-operative to the survey (48.1%).
sequelae of M3M surgery include pain, swelling and
restricted mouth opening (trismus). Complications of
Grade and surgical experience
surgery include infection, alveolar osteitis (dry
socket), injury to the inferior alveolar and lingual Operator seniority in general was high, with 42% of
nerves and occasionally mandibular fracture6. responders qualifying over 20 years ago (Fig. 1).
Morbidity related to M3M surgery can be signifi- Of the responders, the most common grade was
cant to the individual patient and there has been an specialty doctor (25%), followed by primary care
increase in litigation associated with dentoalveolar oral surgeon (18%), associate specialist (18%) and
procedures in recent years7. However, unfortunately oral surgery consultant (13%) (Table 1). Overall,
best practice is still not clearly defined or identified 52% of responders were registered Oral Surgery spe-
leaving the optimisation of surgical training in this cialists with the General Dental Council.
area difficult.
Evidence-based guidelines can be a very useful
support for clinicians and patients in making clinical Years since qualification
decisions and for optimising treatment, where evi- 120
dence may exist8. However, clinical guidelines
100
should be based upon the best available evidence,
which is often scant even for such a high-volume 80
surgical practice. The National Institute of Clinical 60
Excellence (NICE) introduced guidelines relating to 40
M3M surgery in 20009, discouraging the prophylac- 20
tic removal of M3Ms. However, there is growing evi-
0
dence that this may not be in the best interest of the
0-5 6-10 11-15 16-20 >20
patient resulting in delay of inevitable surgery, an
increase in risks of surgery with increasing age and Figure 1 Years since qualification as a dental surgeon.
About 36% of responders stated that M3M surgery 28% of responders would want to schedule a CBCT
comprised of 5075% of their workload and 17% of but had limited access and 34% cited that there was
responders stated that M3M surgery comprised of over not sufficient indication for CBCT.
75% of their workload (Fig. 2). The average surgical Analysis of individual responses showed that some
case load of patients undergoing M3M surgery per clinicians would not request a CBCT scan if a deci-
week was eight local anaesthetic cases, five intravenous sion had been made to perform a coronectomy based
sedation cases and six general anaesthetic cases. on the appearance on plain radiography. Of respon-
ders, 73% would routinely recommended coronec-
tomy for high-risk M3Ms based upon CBCT
Pre-operative assessment and consent
assessment; however, many practitioners in primary
When asked about access to CBCT for risk assessment care would refer the patient to secondary care if they
of M3M, 47% of responders had no problems in felt coronectomy was indicated.
accessing a CBCT scanner. Obstacles to CBCT access Only 4% of responders do not routinely gain
were most commonly attributed to distance (28%), written consent for M3M surgery. About 57%
cost (27%), time constraints (22%), no available undertake a two-stage consent process which is initi-
reporting (10%) and difficulty in interpreting the scan ated at the consultation visit and confirmed on the
(6%) (Table 2). Individual responses also indicated day of surgery. Of responders, 33% gain written
that scans were not always available on the NHS in
primary care, which resulted in some individuals Table 2 Access to CBCT scanning for high-risk M3M
either referring for a private scan or to secondary care. Obstacles to CBCT scanning of high-risk M3M %
In some hospitals, CBCT was not available however
No obstacle easy to access scanner 46.6
spiral or medical CT was offered to high-risk cases.
Distance 28.2
Based upon the presented high-risk example case Cost 27.2
(Fig. 3), 39% of responders would request a CBCT, Time taken to arrange scan 21.8
No arrangement for reporting of scan 9.7
Difficulty interpreting scan 6.3
Table 1 Operator grade
Other 11.7
Which of the following best matches your job title? %
consent on the day of surgery. Individual responses by a buccal infiltration with lidocaine (50%) or arti-
indicate that some practitioners are not able to see caine (39%). Exactly, 6% of responders use articaine
patients for a consultation before the day of surgery IDB regularly and 2% use infiltration only or
but written information on the procedure is sent out intraligamental techniques (Table 3).
in advance of the appointment. Based upon the case presented (Fig. 5), 46% of
During the consent process, 64% of responders the responders would use a buccal triangular (3
routinely warned of inferior alveolar and lingual sided) flap, 41% a buccal approach with distal reliev-
nerve injury including numbness, altered sensation ing incision, 11% buccal approach with retraction of
and pain, 7% and 6% warned of only altered sensa- distal soft tissues using a periosteal elevator and 2%
tion or numbness respectively. About 0.5% of other approaches.
responders only warned patients of nerve injury if On questioning about indications for lingual
the surgery was deemed to be high risk. When quali- access, 50% of responders stated they would only
fying warnings of nerve injury during consent,
patients were advised of anatomical areas which Table 3 Local anaesthetic technique for M3M surgery
could be affected, including the lower lip (97%),
LA technique %
tongue (93%), chin (79%), gums (31%), lower teeth
(38%) and other (6%) (Fig. 4A, B). Lidocaine IDB + lidocaine buccal infiltration 49.5
Lidocaine IDB + articaine buccal infiltration 39.3
High concentration agent (e.g. articaine) IDB + buccal infiltration 6.1
Surgical and anaesthetic technique Infiltration only technique (no IDB) 1.4
Intraligamentary infiltration 0.9
Standard local anaesthetic practice involved using Other 2.8
lidocaine inferior dental block (IDB) supplemented
0 20 40 60 80 100
Figure 4 (A) Consent for risk of inferior alveolar and lingual nerve injury. (B) Areas affected by nerve injury.
efits of the procedure for each individual case and population will require IV sedation for dental treat-
discuss this with the patient involved. ment and it is recognised that this number could be
much higher for invasive procedures such as M3M
surgery24. The Index of Sedation Need (IOSN) has
Consent
been proposed and evaluated as a tool for identifying
The majority of responders (57%) undertake a two- patients who require sedation or general anaesthesia
stage consent process for M3M surgery, with only for treatment25. It has been shown to be a useful aid
4% failing to gain any form of written consent. This for clinicians in identifying patients who should be
is in line with guidance from the Department of referred for sedation or GA, taking into account fac-
Health which recommends confirmation of consent tors such as anxiety and treatment complexity25.
at a separate visit for significant procedures, which However, whether or not this tool is used, the final
in the case of M3M surgery would include any decision should rely on agreement between the
treatment undertaken with intravenous sedation or patient and clinician taking into account the views
general anaesthesia18. It is recognised that patients and opinions of both parties. Individual responses to
memory of information given by doctors is poor, this survey stated that the choice between IV seda-
therefore the provision of written information tion and GA was often dictated by the clinical envi-
regarding the risks and benefits of the procedure ronment and facilities with maxillofacial units
and the opportunity to discuss these at a second tending to treat higher numbers of patients under
consultation is of benefit to those undergoing M3M GA26. Recent guidance from the GDC emphasises
surgery19. There was significant variation between that due to the risks associated with GA, all beha-
responders in the information given during the con- vioural and anxiety management techniques should
sent process to describe the risk of injury to the be considered before prescribing treatment under
inferior alveolar and lingual nerve. There is cur- GA27.
rently no guidance on exactly what should be
included in the consent process for M3M surgery.
Surgical technique
Both the General Dental Council and General Medi-
cal Council guidance on consent state that patients The majority of responders (90%) would use an
should be informed of all frequently occurring and inferior dental block with lidocaine, supplemented
rare serious complications which would significantly with a buccal infiltration with lidocaine or articaine
impact on the patients life, rather than only men- for M3M surgery, in line with current UK practice.
tioning those which the clinician deems likely to About 6% used articaine or another high concen-
occur20,21. The law relating to consent for medical tration agent for IDB, which has been associated
treatment has changed following the Supreme with a higher incidence of inferior alveolar nerve
Court judgement in Montgomery versus Lanarkshire injury28. Flap design was fairly evenly split between
Health Board in March 2015, bringing it in line buccal triangular (46%) and buccal envelope (41%)
with GDC and GMC guidance22. In the case of third for the M3M shown. A recent systematic review
molar surgery, nerve injury should be considered a reported moderate evidence that triangular flaps are
significant complication to the individual patient, associated with a reduction in alveolar osteitis at
with many studies confirming the serious psychoso- 1 week and pain at 24 hours compared to envelope
cial impact these injuries can have23. There is a flaps. There was low-quality evidence of increased
need for further guidance and clarity on the swelling at 1 week with triangular flaps when com-
consent process for third molar surgery, with the pared to envelope flaps6. Routine use of lingual
possibility of standardised consent forms being made retraction was reported by 27% of responders,
available to clinicians. while others would use it for selected complex
cases to aid visualisation and bone removal. Use of
lingual retraction has been shown to increase the
Choice of anaesthesia/anxiety management
risk of temporary lingual nerve injury, although an
On average, each responder was carrying out 19 increased risk of permanent lingual nerve injury
M3M cases per week (eight local anaesthesia, five has not been demonstrated6. Therefore, if surgeons
intravenous sedation and six general anaesthetic are using this technique, patients should be
cases). This survey did not explore the criteria used informed during the consent process of the
by responders in choosing an anxiety management increased risk of lingual nerve paraesthesia which
technique. There is evidence that around 7% of the may last for several weeks following surgery. Most
responders (92%) would use a sectioning technique ning of high-risk cases and the differences in
to conserve alveolar bone during M3M surgery. To approach to pre-operative planning, consent and sur-
the authors knowledge, there is no evidence on gical technique between responders. The reported
the post-operative complications of bone removal rates of inferior alveolar and lingual nerve injuries
versus tooth sectioning; however, intuitively con- caused by M3M surgery varied widely between sur-
serving bone should be in the best interests of the geons; however, this may be due to a lack of post-
patient. operative contact or follow-up with patients there-
fore preventing surgeons from accurately recording
their surgical outcomes. There is a need for further
Post-operative follow-up
high-quality research and evidence-based guidelines
Post-operative follow-up for patients undergoing on radiographic features of high-risk M3Ms, indica-
M3M surgery was rare with only 18% of those sur- tions for coronectomy and incidence of neuropathy
veyed making any type of proactive contact with the to inform best practice in this high-volume surgical
patient within 48 h of surgery. Studies have shown procedure.
that home-check telephone contact is favoured by
patients over a clinic review following M3M sur-
gery29 and is a useful way for surgeons to record Funding
their own outcomes and identify complications early. None.
Telephone follow-up has also been shown to
increase patient satisfaction with treatment received
and reduce re-attendance rates30. Conflict of Interest
The authors confirm that there are no conflicts of
Experience of nerve injury interest.
The average rate of self-reported inferior alveolar
nerve injury (2 temporary, 0.4 permanent) and lin- Ethical Approval
gual nerve injury (1 temporary, 0.1 permanent) in
the past 5 years is low among this group of respon- None required.
ders; however, the numbers vary widely between
clinicians. This may be due to some clinicians taking
References
on a greater number of high-risk cases in secondary
care units. The incidence of IANI following M3M 1. McArdle L, Renton T. The effects of NICE guidelines
surgery has been reported to vary from 0.35% to on the management of third molar teeth. Br Dent J
8.4%31. A similar questionnaire study of Oral and 2012;213:17.
Maxillofacial Surgeons in the USA reported average 2. Faculty of Dental Surgery (The Royal College of Sur-
rates of 4 per 1000 (IANI) and 1 per 1000 cases geons of England). The management of patients with
(LNI)32. The lack of routine follow-up or continuity third molar (syn: wisdom) teeth. 1997. Available
of care following M3M surgery mean that many from http://www.rcseng.ac.uk/fds/publications-clini-
cal-guidelines/clinical_guidelines/documents/3rdmo-
clinicians in this group are unaware of the numbers
lar.pdf [accessed 12 August 2015].
of nerve injuries caused and therefore the results
3. Dogramaci EJ, Naini FB. Impacted maxillary canines:
of our survey should be interpreted with some
contemporary management and review of the litera-
caution.
ture. Fac Dent J 2012;3:2107.
4. AAOMS. White paper. Evidence based third molar
Conclusion surgery. 2013. Available from http://www.aaom-
s.org/images/uploads/pdfs/evidence_based_third_mo-
Mandibular third molar surgery is one of the most lar_surgery.pdf [accessed 12 August 2015].
common outpatient procedures carried out in the 5. McGrath C, Comfort MB, Lo EC, Luo Y. Can third
UK NHS. BAOS members represent one of the main molar surgery improve quality of life? A 6-month
workforces providing this service. Just over half of cohort study. J Oral Maxillofac Surg 2003;61:759
the membership is on the GDC specialist list, how- 63.
ever the proportion of consultant grade surgeons 6. Coulthard P, Bailey E, Esposito M, Furness S, Renton
was only 13%. This survey has highlighted the lack TF, Worthington HV. Surgical techniques for the
of access to CBCT scanning for pre-operative plan- removal of mandibular wisdom teeth. Cochrane
Database Syst Rev 2014;7:CD004345. doi: 10.1002/ 19. Brosnam T, Perry M. Informed consent in adult
14651858.CD004345.pub2. patients: can we achieve a gold standard? Br J Oral
7. Gulati A, Herd MK, Nimako M, Anand R, Brennan Maxillofac Surg 2009;47:18690.
PA. Litigation in National Health Service oral and 20. General Dental Council. Principles of patient con-
maxillofacial surgery: review of the last 15 years. Br sent. 2005. Available from http://www.gdcuk.org/
J Oral Maxillofac Surg 2012;50:3858. Dentalprofessionals/Standards/Documents/Patient
8. Keeley PW. Clinical guidelines. Palliat Med 2003;17 Consent%5b1%5d.pdf [accessed 12 August 2015].
(36837):4. 21. General Medical Council. Consent: patients and doc-
9. National Institute for Clinical Excellence. Guidance tors making decisions together. 2008. Available from
on the extraction of wisdom teeth. London: NICE, http://www.gmc-uk.org/static/documents/content/
2000. Available from http://egap.evidence.nhs.uk/ Consent_-_patients_and_doctors_making_decisions_
guidance-on-the-extraction-of-wisdom-teeth-ta1 [ac- together-english.pdf [accessed 12 August 2015].
cessed 12 August 2015]. 22. DCruz L, Kaney H. Consent a new era begins. Br
10. NHS Commissioning Board. Securing excellence in Dent J 2015;219:579.
commissioning NHS dental services. 2013. Available 23. Smith JG, Elias LA, Yilmaz Z, Barker S, Shah K,
from http://www.england.nhs.uk/wp-content/uploa Shah S et al. The psychosocial and affective burden
ds/2013/02/commissioning-dental.pdf [accessed 12 of posttraumatic neuropathy following injuries to the
August 2015]. trigeminal nerve. J Orofac Pain 2013;27:293303.
11. ONeill E, Gallagher JE, Kendall N. A baseline audit 24. Goodwin M, Pretty IA. Estimating the need for den-
of referral and treatment delivered to patients in the tal sedation. 3. Analysis of factors contributing to
intermediate minor oral surgery service in Croydon non-attendance for dental treatment in the general
PCT. Prim Dent Care 2012;19:238. population, across 12 English primary care trusts. Br
12. Bell G. An audit of 600 referrals to a primary care Dent J 2011;211:599603.
based oral surgery service. Br Dent J 2007;203:E6. 25. Liu T, Pretty IA, Goodwin M. Estimating the need
13. European Commission. Cone beam CT for dental for dental sedation: evaluating the threshold of the
and maxillofacial radiology. Evidence based guideli- IOSN tool in an adult population. Br Dent J
nes. 2012. Available from http://www.seden- 2013;214:E23.
texct.eu/files/radiation_protection_172.pdf [accessed 26. Sammut S, Lopes V, Morrison A, Malden NJ. Predict-
12 August 2015]. ing the choice of anaesthesia for third molar surgery
14. Matzen LH, Christensen J, Hintze H, Schou S, Wen- guideline or the easy-line? Br Dent J 2013;214:E8.
zel A. Influence of cone beam CT on treatment plan 27. General Dental Council UK. Maintaining Standards.
before surgical intervention of mandibular third Guidance to Dentists on Professional and Personal
molars and impact of radiographic factors on decid- Conduct. Section 4.7 Resuscitation, sections 4.17-
ing on coronectomy vs surgical removal. Dentomax- 4.24 General Anaesthesia. November 1997, revised
illofac Radiol 2013;42:98870341. May 1999.
15. Rood JP, Shehab BA. The radiological prediction of 28. Hillerup S, Jensen RH, Ersbll BK. Trigeminal nerve
inferior alveolar nerve injury during third molar sur- injury associated with injection of local anesthetics:
gery. Br J Oral Maxillofac Surg 1990;28:205. needle lesion or neurotoxicity? J Am Dent Assoc
16. Long H, Zhou Y, Liao L, Pyakurel U, Wang Y, Lai W. 2011;142:5319.
Coronectomy vs. total removal for third molar extrac- 29. Sittitavornwong S, Waite PD, Holmes JD, Klapow JC.
tion: a systematic review. J Dent Res 2012;91:65965. The necessity of routine clinic follow-up visits after
17. Renton T, Hankins M, Sproate C, McGurk M. A ran- third molar removal. J Oral Maxillofac Surg
domised controlled clinical trial to compare the inci- 2005;63:127882.
dence of injury to the inferior alveolar nerve as a 30. Braun E, Baidusi A, Alroy G, Azzam ZS. Telephone
result of coronectomy and removal of mandibular follow-up improves patients satisfaction following hos-
third molars. Br J Oral Maxillofac Surg 2005;43:712. pital discharge. Eur J Intern Med 2009;20:2215.
18. Department of Health. Reference guide to consent 31. Sarikov R, Juodzbalys G. Inferior alveolar nerve
for examination and treatment, Second edition. injury after mandibular third molar extraction: a lit-
2009. Available from https://www.gov.uk/govern- erature review. J Oral Maxillofac Res 2014;5:e1.
ment/uploads/system/uploads/attachment_data/file/ 32. Robert RC, Bacchetti P, Pogrel MA. Frequency of
138296/dh_103653__1_.pdf [accessed 12 August trigeminal nerve injuries following third molar
2015]. removal. J Oral Maxillofac Surg 2005;63:7325.