Abstract
Objective: To investigate whether smoking has adverse effects in simple exodontia. Methods: A single-centre, prospective study of postoperative inflammatory complications in simple exodontia was performed. All procedures were conducted under similar and sterile conditions. Postoperative complications (PCs) in exodontia were classified as alveolar osteitis (AO) or alveolar infection (AI) and their incidences then added. Results: A logistic regression model for PCs revealed tooth sectioning [odds ratio (OR) = 4.3, 95% confidence interval (CI) 1.0–18.8; P = 0.050], smoking (OR = 4.5, 95% CI 1.0–18.9; P = 0.03) and amount of smoking (> 20 cigarettes/day: OR = 12.3, 95% CI 1.0–149.8; P = 0.04) to be associated with the occurrence of PCs. Conclusions: Tooth sectioning, smoking and degree of smoking are all associated with the development of PCs such as AO and AI after simple exodontia. Dentists must be alert to these factors when performing simple exodontia in smokers in view of the increased risk for PCs.
Key words: Alveolar osteitis, dental infection, smoking
INTRODUCTION
Tobacco smoking is widely documented to have several adverse effects and has been implicated in several diseases, mainly those of the cardiovascular and respiratory systems. It is also considered to be associated with surgical outcome and the development of complications during and after many types of surgery1., 2.. The relative risk for complications after surgery is reported to be 1.2–5.5 times greater in smokers than in non-smokers2.
Although it is well documented that smoking has deleterious effects in many types of surgery, little recent information is available on whether it has any impact in uncomplicated exodontia3.
METHODS
This research was conducted in full accordance with the World Medical Association Declaration of Helsinki and was approved by the university’s Ethical Committee for Human Research [Comitê de Ética em Pesquisa em Seres Humanos e Animais da Unoesc e Hust, Universidade do Oeste de Santa Catarina (http://unoesc.edu.br/unoesc/pesquisa/comite-de-etica-em-pesquisa); no. 250/2005]. All participants gave signed informed consent. A single-centre, prospective study of postoperative inflammatory complications in simple and erupted teeth exodontia was performed. All procedures were conducted by undergraduate students under similar conditions between March 2007 and December 2011. Data were collected using questionnaires administered to patients and to the students who performed the procedures. Questionnaires were completed before, immediately after and 7 days after surgery. Patients were reassessed at 7 days postoperatively or before or after this date as necessary. All procedures were performed in sterile conditions, which included the use of sterile surgical aprons, sheets and gloves. Extractions of third molars that had not fully erupted and/or were classified as difficult for undergraduate students to remove and extractions of deciduous teeth were excluded from this study.
Postoperative complications (PCs) after exodontia were first classified as either alveolar osteitis (AO) or alveolar infection (AI) and were then combined. Criteria for AO and AI were based on clinical conditions previously described by several authors4., 5., 6., 7..
Statistical analyses were conducted using standard logistic regression in stata Version 8.0 (StataCorp LP, College Station, TX, USA) to compute odds ratios (ORs), P-values and 95% confidence intervals (CIs).
RESULTS
This study prospectively evaluated 793 surgical procedures to remove a total of 1,022 permanent erupted teeth. The sample was composed predominantly of male patients (n = 456, 57.5%). A total of 62 questionnaires were excluded as a result of lack of information, inconsistency or lack of contact with the patient; none of these questionnaires referred to patients with any PC. The mean ± standard deviation (SD) age of the patients was 41.6 ± 16.0 years (range: 9–85 years). The mean ± SD time taken to accomplish the surgical procedure from local anaesthesia to final suture was 41.8 ± 25.9 min.
A total of 185 (23.3%) of the sample were smokers. Of these, 160 patients smoked ≤ 20 cigarettes/day and 25 smoked > 20 cigarettes/day. Postoperative complications occurred in 10 patients (1.3%); AO was diagnosed in four patients (0.5%) and AI in six (0.8%).
A binary logistical model was created to evaluate several variables of interest (Table 1).
Table 1.
Standard binary logistic model including variables for postoperative complications (alveolar osteitis + alveolar infection) after simple exodontia (n = 793)
| Postoperative complication | P-value* | ORadjusted | 95% CI for OR | ||
|---|---|---|---|---|---|
| No, n (%) | Yes, n (%) | ||||
| Gender | |||||
| Male | 452 (57.0) | 4 (0.5) | |||
| Female | 331 (41.7) | 6 (0.8) | 0.2 | 2.5 | 0.5–13.3 |
| Age, years | |||||
| ≤ 33 | 265 (33.4) | 6 (0.8) | 0.4 | 3.9 | 0.3–39.6 |
| 34–47 | 260 (32.8) | 3 (0.4) | 0.2 | 1.9 | 0.1–19.9 |
| ≥ 48 | 258 (32.5) | 1 (0.1) | 0.5 | ||
| Tobacco | |||||
| User (≤ 20 cigarettes/day) | 156 (17.7) | 4 (0.5) | 0.04 | 4.5 | 1.0–18.9 |
| User (> 20 cigarettes/day | 24 (3.0) | 1 (0.1) | 0.03 | 12.3 | 1.0–149.8 |
| Non-user | 603 (76.0) | 5 (0.6) | 0.04 | ||
| Oral contraceptive | |||||
| Yes | 99 (12.5) | 3 (0.4) | 1.8 | 0.3–10.7 | |
| No | 684 (86.3) | 7 (0.9) | 0.5 | ||
| Ostectomy | |||||
| Yes | 93 (11.7) | 4 (0.5) | 1.5 | 0.2–8.0 | |
| No | 690 (87.0) | 6 (0.8) | 0.6 | ||
| Tooth sectioning | |||||
| Yes | 93 (11.7) | 4 (0.5) | 4.3 | 1.0–18.8 | |
| No | 690 (87.0) | 6 (0.8) | 0.050* | ||
| Duration of surgery | |||||
| ≤ 25 min | 233 (29.4) | 2 (0.3) | 0.7 | 0.1–3.8 | |
| > 25 min | 550 (69.4) | 8 (1.0) | 0.7 | ||
| Intraoperative complications (e.g. tooth fracture) | |||||
| Yes | 63 (7.9) | 2 (0.3) | 1.8 | 0.2–11.6 | |
| No | 720 (90.8) | 8 (1.0) | 0.5 | ||
Values in bold are significant at P ≤ 0.05.
OR, odds ratio; 95% CI, 95% confidence interval.
DISCUSSION
Given that simple tooth extraction is one of the most common oral surgical procedures, it is surprising that the literature gives very little attention to the subsequent occurrence of PCs; this may be because PCs in this context are uncommon, although not rare. This study recorded a PC rate of 1.3%, whereas Adeyemo et al.5 observed an overall PC rate of 10.5% (AO, 8.6%; AI, 1.9%) in non-surgical dental extractions. Oginni et al.8 reported the development of PCs (only AO) in 4.1% of 3,319 dental extractions. In third molar surgeries, Haug et al.9 observed a PC rate of 15.9% (AO, 14.7%; AI, 1.2%).
In oral surgery, smoking has been associated with the occurrence of PCs (AO) mainly in the context of dental extractions4., 10., 11.. Smoking has also been associated with an increased risk for severe discomfort after third molar surgery12 and increased levels of pain in periapical surgery13. However, this has been subject to discussion since Al-Khateeb and Alnahar14 observed that non-smokers reported significantly higher pain scores than smokers. Although some authors have reported an association between smoking and PCs4., 10., 11., others have not15., 16.. Nusair and Goussous17 found no difference in the rate of socket healing between smokers and non-smokers.
Heng et al.10 assessed the association of smoking with the occurrence of PCs, including pain, swelling, bleeding and AO, and found smoking to be related to increases in these PCs after dental extraction. Al-Belasy11 observed an increased rate of PCs (AO) following the extraction of mandibular molars in water pipe smokers compared with non-smokers (26% vs. 7%) and, similarly, found the incidence of AO to be higher in cigarette smokers than in non-smokers (16% vs. 7%). In general, this study’s findings support the evidence that smoking cigarettes may increase the risk for PCs following simple tooth extraction.
Smoking has been associated with delayed wound healing as a result, in part, of the actions of nicotine as a vasoconstrictor and promoter of platelet adhesiveness and thrombotic microvascular occlusion, all of which contribute to tissue ischaemia18. With regard to bone regeneration, nicotine has been shown to inhibit osteogenesis, vascularity and bone lengthening in mandibular distraction angiogenesis in an animal model19.
The present study also identified an association of borderline statistical significance between tooth sectioning and increased risk for PCs. This may be explained by an increase in surgical trauma as 41.2% of the patients who underwent tooth sectioning also underwent ostectomy. In a recent review article, Noroozi and Philbert20 declared that the majority of the literature supports a link between the development of PCs such as AO and increased surgical trauma. According to Blum4, it seems logical that fragments of debris that remain after normal extraction or the surgical removal of teeth may disturb the wound-healing process and thereby possibly contribute to the development of PCs in the form of AO.
CONCLUSIONS
This study found that tooth sectioning, smoking and degree of smoking (especially > 20 cigarettes/day) are each associated with the development of PCs such as AO and AI after simple exodontia.
Acknowledgements
The authors wish to thank the Fundação de Apoio a Pesquisa Científica e Tecnológica do Estado de Santa Catarina (FAPESC) and the Universidade do Oeste de Santa Catarina for partial financial support of this research.
Conflicts of interest
None declared.
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