International Journal of Dentistry and Oral Health Volume 4 Issue 12 December, 2018

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1 Research Article International Journal of Dentistry and Oral Health Wound management in mandibular third molar surgery among dentists in Riyadh, Saudi Arabia Abstract ISSN X Abeer AL-Matrodi *1, Ahlam AL-sharif 1, Fatimah AL-Sharif 1, Samaher Alquwifel 1, Hisham Dwadre 2 1 D.D.S General Dental Practitioner Graduated from Alfarabi Private College 2 D.D.S, M.Sc in oral maxillofacial surgery. Faculty member in oral & maxillofacial surgery sciences Department, Alfarabi Dental College Introduction: The mandibular third molar extraction is associated with different types of postoperative complications including dysesthesia, dry socket, trismus and the most common being dry socket. Materials and methods: This is a cross-sectional study and participants were recruited via non-random cluster sampling using a validated questionnaire from Clinic for Oral and Maxillofacial Surgery, Cantonal Hospital Lucerne, Switzerland (15) to determine the awareness and knowledge of dentist toward (MTM) wound management, mouth rinse, and prophylaxis antibiotic. Results: N=276 dentists participated in this study, of which 65.1% were males while 34.9% were females, and 96 of them oral surgery certificated and 182 general practitioners. a significant difference exist between certified oral surgery dentist versus non-certified oral surgery dentist in terms of the kind of flap for removal partially impacted MTM 56.3% of the oral surgery certified preferred a three-sided flap with release incision, and the general practitioner dentist reported a 62.7% of them preferred use the envelope flap without release incision.the most common wound closure after extraction the mandibular third molar are 51.6% of the oral surgery certified preferred use semi-closer without dressing only blood clot. and 53.0% of the general practitioner they mainly going with primary closer without dressing only blood clot. the study found significant difference <0.001 of oral surgery certified in prescribe antibiotics 47 times more than non-certified of the oral surgery. Conclusion: It can be concluded that dental practitioners having postgraduate certificate in surgery tend to have better expertise in the management of mandibular molars. Significant difference in surgical practice was also observed between males and females Keywords: Mandible third molar,wound managment,impacted third molar,saudi Dentist Corresponding author: Abeer AL-Matrodi, D.D.S General Dental Practitioner Graduated from Alfarabi Private College, E mail: abeeralmatrodi@outlook.sa Citation: Abeer AL-Matrodi et al. (2018), Wound management in mandibular third molar surgery among dentists in Riyadh, Saudi Arabia. Int J Dent Copyright: 2018 Abeer AL-Matrodi et al. This is an openaccess article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Received: October 22, 2018 Accepted: November 02, 2018 Published: December 20, 2018 Introduction Dent-alveolar surgery of third molar extraction is a procedure mainly performed by oral maxillofacial surgeon, OMFs resident and experience general dentist (GDPs). The mandibular third molar extraction is associated with different types of postoperative complications including dysesthesia, dry socket, trismus and the most common being dry socket (alveolar osteitis) (1). The alveolar osteitis occurs in about 25 30% patients after extractions of mandibular third molar (2). There are multiple factors associated with the occurrence of postoperative complication include smoking habits, age, medical status of patient and the type of mandibular third molar impaction (3). In 2008, department of maxillofacial surgery in Georgia university conducted a study among 500 patients, who had undergone surgical extraction for impacted third molar by the resident of OMFs. Among the sample, 280 patients had at least on complication after the procedure (4). Another study in United States suggested that the extractions done by OMFs in 3,760 patients led to complications occurring only in less than 1% (5), which proves the importance of dentists experience in performing extractions for impacted third molars (3). Another complication related with the surgery of mandibular third molar is bacteremia infection, as it is an acute infection that spreads to the facial spaces and leading to airway obstruction (6). There are multiple reasons behind extraction of third molar, which include odontogenic lesions (cysts, tumors), periodontal complication, secondary caries to adjacent teeth and pericoronitis (acute-chronic) (7). Antibiotic therapy 187

2 after mandibular third molar extraction is commonly practiced among dentists. However, a study by Staffolani et al (1999) found no significant effect of prophylactic antibiotic in postoperative complication after third molar extraction (8). On the other hand, a study trial was done using topical tetracycline after extraction third molar, which resulted in prevention of dry socket (6). Another investigation done by Penarrocha et al (2001) studied the effect of chlorohexidine mouth wash usage before the procedure that led to decreased post-operative complication (9). The prevalence of mandibular third molar impaction is higher than the maxillary impaction by 57.58%, as far as worldwide data is concerned (10). In Saudi Arabia, the ratio of mandibular to maxillary third molar impaction in population was 2.68:1 (11). Type of flap design used plays an important role in the wound healing as far as third molar extraction is concerned. A modified triangular flap was found to be much more useful in the wound healing process as compared to other techniques (20). Many studies have been conducted to demonstrate different techniques of wound management after extraction of mandibular third molar (open wound-semi-closure-full-closure) (12) (13) (14). In a similar study by Swiss Dental Society (SSO), they assessed the knowledge and practice of Swiss dentists regarding wound management and the use of mouth rinse in surgical removal of mandibular third molars (MTM). Among all 3,288 dentists who were the members of SSO, the response rate was 55% and revealed that semi-closed (59.1%), full closed (19%) and open wound management (11.7%) was conducted by them. Most dentists (74.5%) prescribed chlorhexidine 0.2% (CHX) mouth rinse when performing MTM surgery and a combination of preoperative and postoperative use and most of them having no using antibiotic with MTM (15), (21). Objectives of the Study Aim of the Study To evaluate the knowledge and practice of dentists in Riyadh towards the wound management after mandibular third molar surgeries. Specific Objectives 1- To identify the difference of practice between oral surgery certificate and general practice dentistry toward management of mandibular third molar extraction. 2- To know the variation of educational background that are associated with management of mandibular third molar Materials and Methods This study was conducted in Riyadh, Saudi Arabia. Non-randomized selection of dentists was performed government-run hospitals and private clinics around the city. This is a cross-sectional study and participants were recruited via non-random cluster sampling using a validated questionnaire from Clinic for Oral and Maxillofacial Surgery, Cantonal Hospital Lucerne, Switzerland (15) to determine the awareness and knowledge of dentist toward (MTM) wound management, mouth rinse, and prophylaxis antibiotic. Inclusion criteria comprises of males and females, OMF surgeons, OMFS residents and general dentist dealing with dento-alveolar surgery. Whereas, exclusion criteria comprise of dental interns, dental students and other dental specialty that does not deal with dento-alveolar surgery. Study design and sampling: Our study is a convienient cross-sectional questioner study as we contacted with the respondents only at one point of time. Also, this type of study design allowed us to evaluate the knowledge and practice of target dentists working in Riyadh toward wound management and mouth rinse in mandibular third molar surgery. This allowed us to know the difference between surgical experience and educational level according to the management technique. By using raosoft website, an open sample size calculator, a sample size of 275 dentists was needed to achieve the results. This is based on the Ministry of Health yearly statistics booklet 2016, which showed that there are total of 5122 dentists working in Riyadh (16). The margin of error is chosen to be 5% and the confidence level is 95% with the worldwide prevalence of mandibular third molar impaction 57.58% based on last study. Non-random convenient sampling technique We will recruit participants to cluster sampling. We divided Riyadh into 15 addministrative areas according to The High Commission for the Development of Riyadh. We states all the government-run hospitals and private clincs in an excel sheet as we chose 5 government-run hospitals and 5 private clinics. We contacted all the available dentists and they were asked to fill the questionnaire. Data collection methods and management: Data from participants was collected through in-person structured intreviews by the research team using a previously validated questionaire from Clinic for Oral and Maxillofacial Surgery, Cantonal Hospital Lucerne, Switzerland. The questionnaire consisted of 5 parts: first part was demographic data (age, year of dentist qualification, university, location of practice, surgical board certification). Second part included suturing experience, third part involved antibiotic related questions (multi answer), fourth part had wound closure (single answer) and fifth part about mouth rinse (multi answer). Statistical package for the social sciences (SPSS) version 23 was used for data entry and data analysis. Frequencies and percentages were generated for categorical variables, while mean and standard deviation were calculated for quantitative variables. Confidence interval of odds ratio and the p-value were generated for different wound closure,mouth rinse and antibiotic in management. Test with a P-value < 0.05 was considered to be statistically significant. Person s Chi-square test and logistic Regression were used for observing and quantifying the association between categorical outcomes: 1-Demographic data (Cross tab Person s Chi-square test) 2- Flap of removal Surgery (three- Way cross tab) 3- Antibiotics (Cross tab, Binary logistic Regression) 4-Wound Closure (cross tab, Chi-square) 5-Mouth rinses (Cross tab) Results N=276 dentists participated in this study, of which 65.1% were males while 34.9% were females, 167 Saudis and 109 non-saudis and 96 of them oral surgery certificated and 182 general practitioners. Most of the participants were private practitioners (36.7%) and 25.5% were public employees (table1) (graph1). 188

3 Table1: Demographic characteristics of dentists depending on Oral surgery certificate Graph 1: Qualifications of participants on the basis of nationality Graph2: Experience years among participated dentists. 189

4 33.96% of the general practitioners did extraction of 1 to 5 teeth per month followed by 25.75% extracting 6 to 20 teeth per month. On the other hand, 19.03% of the oral surgery certified did extractions of 6 to 20 teeth per month and 11.57% extracted more than 20 teeth per month (graph 3). Graph3: frequently teeth extraction among general practitioner and oral surgery certified. Regarding the wound closure, most common method used by 51.6% of the oral surgery certified was semi-closed without drain only with blood clot. However, 53.0% of the general practitioners mainly with primary closure without drain only blood clot (table2) (graph4,5,6). Table 2: Certified & non-certified oral surgery dentists and various wound management techniques. Graph 4: Participants opting for open healing on the basis of presence/absence of oral surgery certificate 190

5 Graph 5: Participants opting for semi-closed healing on the basis of presence/absence of oral surgery certificate Graph 6: Primary wound closure according to presence/absence of oral surgery certificate A significant difference exists between certified oral surgery dentists and non-certified oral surgery dentists in terms of the kind of flap for the removal of partially erupted MTM. 56.3% of the oral surgery certified preferred a three-sided flap with release incision for the partially erupted whereas 62.7 of general practitioners reported that they preferred to use the envelope flap when extracting the partially erupted MTM. There are no significant differences between Saudi and non-saudi dentists, in kind of flap removal for fully impacted MTM and closing the wound after MTM extraction. However, there is a difference in flap of removal partially MTM between Saudi dentists and non-saudi dentists. Among Saudi dentists, significant difference exists between certified oral surgery dentists versus non-certified oral surgery dentist in terms of the kind of flap of removal partially MTM. The data also show a significant difference among non-saudi dentists with certificate in closing the wound after MTM extraction. (table 3). 191

6 Table3: Comparing between Saudi and non-saudi dentists with and without oral certificate in kind of flaps used in MTM When comparing the antibiotic prescription between oral surgery certified and GP dentists, both groups prescribe it postoperatively for 3 to 5 days with morning and evening dosage. The study found significant difference <0.001 of oral surgery certified in prescribing antibiotics 47 times more than non-certified oral surgeons. A logistic regression was performed to ascertain the effects of independent variables on antibiotic prescriptions. The logistic regression model was statistically significant P-value < Note that males were 2 times more in prescribing antibiotic than female. (Table 4) Table4: Association between antibiotic prescription of dentists and Variables; Gender; Age; type of work; surgical experience; Qualification; surgical extraction MTM per month; nationality; oral surgery certificate. 192

7 Among all of the participating dentists, 55.8% of them did not prefer to prescribe mouth wash and 25.4% prescribed it postoperative for multiple days (graph7). Graph 7: Prescription of mouthwash among participants. Discussion In this study the most common (by 50.1% dentists) wound closure technique used with mandibular molar extraction was primary wound closure with blood clot only, followed by open healing without drain only blood clot (48.2%) and the last technique semi-closure with blood clot only (43.8%). These findings are comparable to Vlcek (2015) study among the members of the Swiss Dental Society (SSO) where they reported (59.1%) semi-closure (19%) primary closure, and open healing (11.7%). Danda et al (2010) found that the patients in the secondary healing group after surgical extraction of impacted mandibular molar had a significantly lesser amount of postoperatively complication than the primary closure group (14). A significant difference exists among the kinds of flaps for the removal of partially erupted MTM. 56.3% of the oral surgery certified preferred a three-sided flap with release incision for the partially erupted of the MTM, and the general practitioner dentist reported a 62.7% of them preferred use the envelope flap with partially erupted MTM. On other hand Rosa et al found no significant effect of flap designs on the loss of the attachment in the distal side of the second molar after mandibular third molar surgical extraction with or without incision release (19). 65.4% of the dentists preferred to prescribe the antibiotic postoperatively for 3 to 7 days, and the study found the most common antibiotic prescribed among dentist in Riyadh are amoxicillin, which was reported by Lopez et al, who found a significant difference in decreasing the postoperative complication when used amoxicillin post or pre-operative (18), (21). In our survey, most of the dentists (55.8%) did not prescribe mouth wash in mandibular third molar procedure. Whereas 25.4% of dentist mainly prescribed it postoperative for multiple days, and the least mouth wash prescription in MTM surgery were 4.7% preoperative. However, a meta-analysis found that the effect is best when patients start using chlorhexidine preoperatively and continue to use it for one week postoperatively at a concentration of 0.12% (17), (23). Conclusion It can be concluded that dental practitioners having postgraduate certificate in surgery tend to have better expertise in the management of mandibular molars. Significant difference in surgical practice was also observed between males and females. However, no significant comparisons were obtained on the basis of work experience, place of work and number of monthly extractions performed. References 1-Vlcek D, Razavi A, Kuttenberger JJ. Wound management and the use of mouth rinse in mandibular third molar surgery. Swiss Dent J Jan 15; 125: Neville, BW; Damm, DD; Allen, CM; Bouquot, JE. Oral & Maxillofacial Pathology (2nd ed.). Philadelphia: W.B. Saunders p ISBN Farhadi F, Navidi A, Maheri R. Awareness of the Complications from Impacted Third Molar Surgeries among General Dental Practitioners. Advances in Biosciences & Clinical Medicine Jan 1;4(2):32. 4-Sisk AL, Hammer WB, Shelton DW, Joy ED. Complications following removal of impacted third molars: the role of the experience of the surgeon. Journal of oral and maxillofacial surgery Nov 1;44(11): Haug RH, Perrott DH, Gonzalez ML, Talwar RM. The American Association of Oral and Maxillofacial Surgeons age-related third molar study. Journal of oral and maxillofacial surgery Aug 31;63(8): Casas Altarriba J. Prevalence and risk factors of early and delayed postoperative infections after lower third molar surgery: a metaanalysis. 7-Farhadi F, Navidi A, Maheri R. Awareness of the Complications from Impacted Third Molar Surgeries among General Dental Practitioners. Advances in Biosciences & Clinical Medicine Jan 1;4 (2):32. 8-Monaco G, Staffolani C, Gatto MR, Checchi L. Antibiotic therapy in impacted third molar surgery. European journal of oral sciences Dec 1; 107(6): Penarrocha M, Sanchis JM, Saez U, Gay C, Bagán JV. Oral hygiene and postoperative pain after mandibular third molar surgery. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology Sep 30;92(3): Richards D. Prevalence of third molar impaction worldwide. National Elf Service Limited,

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