Decision making in third molar surgery: a survey of Brazilian oral and maxillofacial surgeons

Abstract

This study was designed to evaluate the variations in decision making among Brazilian oral and maxillofacial surgeons (OMFS) and trainees in relation to third molar surgery. A survey on 18 diverse clinical situations related to the assessment and treatment of the third molar surgeries was conducted during the 20th Brazilian National OMFS meeting. Participants were divided into three groups according to their level of training. Another variable studied was length of experience. Correlation between the question answers and the variables was analysed using the chi-square test and the f test. The mean age of participants was 32.68 years, and their mean length of experience was 5.24 years. There were no statistical differences between the level of training and number of years of experience and the responses to 15 of the 18 questions on clinical situations. However, differences were found in responses to prophylactic extraction of asymptomatic third molars, use of non-steriodal anti-inflammatory drugs (NSAIDs) during the preoperative surgical period and the use of additional imaging to plan extractions. The group with shorter time of experience (3.8 ± 3.94 years) tended to recommend extractions of asymptomatic third molars more frequently compared with the more experienced surgeons (P = 0.041). More experienced surgeons used NSAIDs in the preoperative surgical period, whereas the majority of the youngest surgeons (4.1 ± 5.96 years of experience) did not (P = 0.0042). The certificated trained and in practice group tended to treat deep lower third molar impactions based on the findings of a panoramic radiograph, without obtaining additional imaging [cone beam computed tomography (CBCT)] before treatment (P = 0.0132). Decision making regarding third molar treatment differs according to the level of training and is influenced by the number of years of experience. Therefore, further continuous education programmes in this area are warranted to make recommendations regarding third molars consistent with the current literature.

INTRODUCTION

The removal of third molars is one the most common operations in oral surgery. However, controversy exists regarding the best treatment option for a variety of case scenarios. At the same time, the impacted mandibular third molar is arguably the most widely researched subject in oral surgery. In spite of this enormous interest, there is a lack of consensus regarding third molar surgery between oral surgeons¹. Most published guidelines are based on a consensus reached among experts at meetings convened by professional associations, such as the American Association of Oral and Maxillofacial Surgeons (AAOMS).

The management of partially and fully impacted third molars differs among dental practitioners and in different schools and different countries. In Sweden, oral surgeons schedule third molar removal significantly more often compared with their colleagues in the UK². It is difficult to trace the source of differences between the two countries. There may be differences in underlying factors, such as culture (patient demand), treatment methods (local anaesthesia vs. general anaesthesia), economics, as well as personal choice. Within the same country there can be different philosophies of treatment.

In light of the current emphasis on evidence-based decisions in clinical practice, it is prudent to evaluate decisions for or against removal of a mandibular third molar, radiographic assessment of the third molar, assessment of surgical difficulty, prophylactic use of antibiotics, control of short-term postoperative morbidity and prevention of lingual nerve injury. All these factors should be continuously discussed.

The purpose of this study was to analyse the influence of level of training and the surgeon’s experience on third molar surgery decision-making processes by Brazilian oral and maxillofacial surgeons currently working in different environments.

MATERIALS AND METHODS

There were 1180 attendees at the 20th Brazilian National Conference on Oral and Maxillofacial Surgery (COBRAC): residents; specialists with and without board certification; and specialists with Master’s/Doctorate degrees. Participants were asked to complete a questionnaire, developed by the University of Pernambuco post-graduation programme, regarding demographic and work habits related to third molar surgery. To permit comparison of the effects of different levels of education/training, the subjects were divided in three groups, as follows: Residents; Certificated/Specialists trained and in practice; and Certificated trained and in practice with a Master’s degree (MSc) and/or a Doctorate degree (PhD). The second variable studied was length of experience, which was calculated, in years, from the time of graduation from dental school. To collect the data, two postgraduate students in oral and maxillofacial surgery, who were trained and calibrated for use of the questionnaire, interviewed a random sample of attendees during the event that received the questionnaire that was attached to the welcome documentation pack received at the event. The current study was conducted in full accordance with ethical principles, including the World Medical Association Declaration of Helsinki, and received approval from the University of Pernambuco Institutional Ethics Committee (CAAE/UPE 0117.0.097.000-09). All interviewees signed a statement of informed consent.

The questionnaires were generated to access recommendations regarding: the indications for prophylactic removal of asymptomatic third molars; the relationship between third molars and dental crowding; the relationship between third molars and periodontal defects on the adjacent teeth; the routine use of antibiotics; the routine use of corticosteroids; and the routine use of preoperative non-steroidal anti-inflammatory drugs (NSAIDs). Additional questions included asymptomatic impacted third molars with a follicular space up to 2.5 mm wide; use of sedation to perform third molar removal; and existence of emergency equipment and medication in their practice. Finally, participants were asked if the choice of drugs used in third molar surgery was based on personal experience or recent literature.

Different mandibular third molar case scenarios were presented to the participants. They were asked to choose which treatment they would recommend in each case according to the following situation: use of cone beam computed tomography (CBCT) to evaluate the relationship between the root and mandibular canal; and how to manage root tips. Additionally, they were asked about the classifications used to indicate third molar removal; about the systematic sending of follicles for histopathological analysis; and, finally, about the type of incision/flap used, suture used, osteotomy/ostectomy and retraction of the lingual flap. Participants were told to choose only one answer to each question. Those who chose more than one or left any blank were excluded. Residents and oral surgeons were further asked to state when they graduated from dental school.

Before the study began, a pretest of the questionnaire was performed with the participants of an oral and maxillofacial surgery continuing education course at the Pernambuco School of Dentistry, Universidade de Pernambuco (Brazil). Data were collected and analysed, using the Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS Inc, Chicago, IL, USA), by the Department of Statistics of the University of Kentucky. Associations between number of years of experience and level of training related to the treatment choice were analysed using the chi-square test. For comparisons between years of experience and answers, P values were obtained from two sample t-tests of the difference of means for the answer groups. An f test was used to analyse the overall relationship in the variable that had three categories. A value of P < 0.05 was considered statistically significant.

RESULTS

Of 1180 participants, 94 (7.97%) answered the questionnaire in a valid way. The participants included 611 specialists in oral and maxillofacial surgery with different levels of training and 569 residents currently undergoing training in oral and maxillofacial surgery.

Of our sample of participants, 33 had obtained further degrees after training in oral and maxillofacial surgery: 16 had a Master’s degree (MSc) and 17 had a Doctorate degree (PhD). Thirty-two were Oral and Maxillofacial Surgery Board Certificated (Brazil Board of Oral and Maxillofacial Surgery) and 29 were residents. The average (standard deviation) age of the participants was 32.68 (7.97) years. The length of experience was 5.24 ± 6.46 years. The length of time from graduation ranged from 3 months to 32 years and 8 months. The residents who participated performed complicated extractions in their daily practice. This group had a mean of 1.82 years of experience, whereas oral and maxillofacial surgeons with an MSc or a PhD had 7.56 years of experience.

There were no statistical differences between the variables levels of training and length of experience related to 15 of the 18 questions (Table 1). However, differences were found in responses to the prophylactic extraction of asymptomatic third molars, use of NSAIDs during the preoperative surgical period and the use of additional imaging (CBCT) to plan extractions.

Table 1.

Third molar treatment decisions made/recommendations questionnaire

Do you usually perform prophylactic removal of asymptomatic third molars?

Do you believe that the lower third molar is responsible for dental crowding?

Do you believe that the presence of a partially erupted third molar increases the risk of developing periodontal disease in the adjacent teeth?

Panoramic X-ray shows a radiolucency of up to 2.5 mm at its greatest diameter surrounding the crown of a completely impacted asymptomatic third molar. How do you proceed?

Do you usually use sedation for anxious patients during third molar surgery?

In your private office do you have the equipment necessary for initial care in cases of emergencies?

Do you routinely prescribe corticosteroids during third molar surgery?

Do you use NSAID’s as premedication to control pain, swelling and trismus in third molar surgery?

Do you routinely use antibiotic prophylaxis (excluding endocarditis) in the extractions of asymptomatic third molars?

Your choice of medications in impacted third molars surgeries is based on?

Third molars indicated for extraction have a direct relationship between the roots and the mandibular canal in the panoramic X-ray. How would you proceed?

During removal of a third molar the root apex fractures, retaining at least 2 mm of the root. How do you proceed?

To determine the need for removal of an asymptomatic third molar do you use the classification of Pell & Gregory and Winter?

In clinical practice, do you routinely send the follicular tissue for histopathological examination, regardless of its size?

What type of incision/flap do you usually use when performing the third molar surgery?

When you perform the anterior/posterior releasing incision, how do you suture?

What type of system/instrument do you use for extractions of impacted third molar (regardless of upper or lower)?

Do you usually detach and retract the lingual flap for removal of an impacted lower third molar?

NSAID, non-steriodal anti-inflammatory drug.

Table 2 summarises participants’ recommendations for various conditions of third molars. There were no statistical differences between the variables level of training and number of years of experience and the responses given to eight of the 10 questions presented in this table. However, differences were found in responses to the recommendation of prophylactic extraction of asymptomatic third molars (P = 0.041), in which the group with shorter time of experience (mean ± standard deviation: 3.8 ± 3.94 years) recommended this practice more frequently than did the more experienced surgeons (mean ± standard deviation: 8.7693 ± 9.56 years), and to the use of NSAIDs in the preoperative surgical period – the majority of surgeons with shorter time of experience (mean ± standard deviation: 4.1 ± 5.96 years) tended to not use this practice (P = 0.0042).

Table 2.

Correlation of third molar treatment recommendations to the level of training and length of experience

Recommendations	Level of training			Length of experience (years)	Recommendations	Level of training			Length of experience (years)
Prophylactic removal of third molars	General practitioner/Resident	Yes	72.41%	1.82	Have equipment for emergency care in the private dental office	General practitioner/Resident	Yes	68.96%	1.82
		No	27.59%				No	31.04%
	Specialist/Board certificated	Yes	65.62%	5.93		Specialist/Board certificated	Yes	87.05%	5.93
		No	34.38%				No	12.05%
	Master’s degree/PhD	Yes	75.75%	7.56		Master’s degree/PhD	Yes	87.88%	7.56
		No	24.24%				No	12.12%
Believes that lower third molar causes dental crowding	General practitioner/Resident	Yes	27.59%	1.82	Use corticoid prophylaxis (as pre- and postoperative medication for pain, oedema and trismus control)	General practitioner/Resident	Yes	58.62%	1.82
		No	72.41%				No	41.38%
	Specialist/Board certificated	Yes	34.38%	5.93		Specialist/Board certificated	Yes	65.63%	5.93
		No	65.62%				No	34.37%
	Master’s degree/PhD	Yes	36.36%	7.56		Master’s degree/PhD	Yes	69.70%	7.56
		No	63.64%				No	30.30%
Believes that third molars can cause periodontal defects in adjacent tooth	General practitioner/Resident	Yes	82.76%	1.82	Use of NSAIDs (as preoperative medication for pain, oedema and trismus control)	General practitioner/Resident	Yes	13.80%	1.82
		No	17.24%				No	86.20%
	Specialist/Board certificated	Yes	81.25%	5.93		Specialist/Board certificated	Yes	34.37%	5.93
		No	18.75%				No	65.63%
	Master’s degree/PhD	Yes	75.76%	7.56		Master’s degree/PhD	Yes	30.31%	7.56
		No	24.24%				No	69.69%
Removal versus follow up of asymptomatic third molars with 2.5-mm-wide follicle on panoramic radiographs	General practitioner/Resident	Remove	75.86%	1.82	Use of antibiotic prophylaxis (excluding endocarditis)	General practitioner/Resident	Yes	72.41%	1.82
		Follow up	24.14%				No	27.59%
	Specialist/Board certificated	Remove	84.38%	5.93		Specialist/Board certificated	Yes	65.62%	5.93
		Follow up	15.62%				No	34.38%
	Master’s degree/PhD	Remove	75.76%	7.56		Master degree/PhD degree	Yes	75.76%	7.56
		Follow up	24.24%				No	24.24%
Use of sedation for third-molar removal	General practitioner/Resident	Yes	44.82%	1.82	Choice of medications to be used in third molar surgery is based on:	General practitioner/Resident	Individual experience	44.83%	1.82
		No	55.18%				Scientific data	55.17%
	Specialist/Board certificated	Yes	53.13%	5.93		Specialist/Board certificated	Individual experience	50%	5.93
		No	46.87%				Scientific data	50%
	Master’s degree/PhD	Yes	51.52%	7.56		Master’s degree/PhD	Individual experience	27.27%	7.56
		No	48.48%				Scientific data	72.73%

NSAIDs, non-steroidal anti-inflammatory drugs.

Table 3 presents the distribution of decision making according to the surgical technique used by surgeons during the extraction. Again, there were no statistical differences between the variables studied in the responses to seven of the eight questions presented in the table. Here, the exception occurred in the group of specialist/board certified surgeons. They tended to treat deep lower third molar impactions based only on the findings of a panoramic radiograph without obtaining additional imaging (CBCT). This same group used coronectomy as a treatment plan twice as frequently as residents and those in the MSc/PhD degree group, to access deep lower third molars in which the root was associated with the inferior alveolar nerve (P = 0.0132).

Table 3.

Correlation of third molar treatment decisions made to the level of training and length of experience

Decisions made	Level of training			Length of experience (years)	Decisions made	Level of training			Length of experience (years)
Use of CBCT to evaluate close relationship between root apex and mandibular canal	General practitioner/Resident	CBCT	65.51%	1.82	Type of incision/flap	General practitioner/Resident	Envelope	41.38%	1.82
		Panoramic	31.04%
		Perform coronectomy w/o CBCT	3.45%				With anterior releasing incision	58.62%
	Specialist/Board certificated	CBCT	37.5%	5.93		Specialist/Board certificated	Envelope	40.63%	5.93
		Panoramic	53.13%
		Perform coronectomy w/o CBCT	9.37%				With anterior releasing incision	59.37%
	Master’s degree/PhD	CBCT	75.76%	7.56		Master’s degree/PhD	Envelope	39.39%	7.56
		Panoramic	21.21%
		Perform coronectomy w/o CBCT	3.03%				With anterior releasing incision	60.61%
Transoperative root apex (<2 mm) fractured during extraction	General practitioner/Resident	Remove	31.03%	1.82	Type of flap suture	General practitioner/Resident	Hermetic/tight	68.97%	1.82
		Leave	68.97%				W/spaces for drainage	31.03%
	Specialist/Board certificated	Remove	28.13%	5.93		Specialist/Board certificated	Hermetic/tight	75%	5.93
		Leave	71.87%				W/spaces for drainage	25%
	Master’s degree/PhD	Remove	33.33%	7.56		Master’s degree/PhD	Hermetic/tight	72.73%	7.56
		Leave	66.67%				W/spaces for drainage	27.27%
Use classification of Pell & Gregory/Winter to indicate asymptomatic removals	General practitioner/Resident	Yes	48.28%	1.82	Type of osteotomy/ostectomy	General practitioner/Resident	Turbines	96.55%	1.82
		No	51.72%				Low/medium speed	3.45%
	Specialist/Board certificated	Yes	50%	5.93		Specialist/Board certificated	Turbines	90.63%	5.93
		No	50%				Low/medium speed	9.37%
	Master’s degree/PhD	Yes	48.48%	7.56		Master’s degree/PhD	Turbines	75.75%	7.56
		No	51.52%				Low/medium speed	24.25%
Systematic sending of follicles, regardless of size, for histopathology assessment	General practitioner/Resident	Yes	6.90%	1.82	Release of lingual flap in lower thirds	General practitioner/Resident	Yes	20.69%	1.82
		No	93.10%				No	79.31%
	Specialist/Board certificated	Yes	9.38%	5.93		Specialist/Board certificated	Yes	15.63%	5.93
		No	90.62%				No	84.37%
	Master’s degree/PhD	Yes	24.24%	7.56		Master’s degree/PhD	Yes	18.18%	7.56
		No	75.74%				No	81.82%

CBCT, cone beam computed tomography; W, with; w/o, without.

DISCUSSION

Third molar removal is one of the most frequently performed operations in oral and maxillofacial surgery. The issues studied here were obtained from published data that reported differences between junior surgeons and a group of surgeons in planning treatment of third molars. Because of the relative lack of experience of residents, they might interpret the situation differently, and make different recommendations, compared with senior surgeons. It was expected that those with less experience would underestimate surgical difficulty³. Differences in treatment planning are not only related to the surgeon’s experience but can also be the result of cultural influences, as seen in different countries and even in the same country¹. The attendees at the 20th Brazilian Oral and Maxillofacial Surgery Meeting were very heterogeneous and comprised surgeons from all the states of the Brazilian confederation. Our questionnaire did not evaluate the aspect of institution of training; therefore, we could not correlate this to our results.

A recent publication concluded that the preoperative prediction of the surgical difficulty of mandibular third molar tooth removal is unreliable, not only for residents, but also for senior surgeons⁴. An example of this is that the majority of responses to questions in our survey did not show statistical differences between the groups when the length of experience and level of training was considered for the treatment planning of third molar surgery. This pattern of division of opinions can be observed in our findings seen in both tables. Choice of medications, use of sedation and use of antibiotics was almost evenly split between the groups. In relation to antibiotic use, a pattern similar to that in the present study has also been described by the AAOMS, who reported that such therapy may or may not help⁵. Regarding the use of sedation, despite the fact that one recent study concluded that impacted lower third molar extractions are significantly more difficult in anxious patients⁶, Brazilian surgeons did not demonstrate a general tendency to follow this practice. This same pattern of divided opinion occurred with: type of incision; osteotomy; flap and suture used; the scientifically based choice of medications; removal or follow up of a tooth with radiographic signs of pathology; as well as systematic referral of follicles for pathology analysis. All of those recommendations/decisions made were different among the groups of surgeons, based on reports of their day-to-day practices (Tables 2 and 3). The other variables studied (i.e. questions), for which we found significant differences, are discussed in the next section.

Prophylactic removal of the third molar

Management of asymptomatic partially and fully impacted mandibular third molars differs among dental practitioners⁷. Survey studies performed in Oral Surgery Clinics in Sweden found that the indication for removal was classified as prophylactic in 27% and orthodontic in 14%⁸ in which there is great variation among oral surgeons in their judgment on the need for removal of asymptomatic mandibular third molars⁹, where the only factor that influenced the indication for removal of molars with no disease was the patient’s age.¹⁰

Our results showed that the level of experience influences the decision-making process. We found that surgeons with more than 8 years of experience prefer to follow up, rather than extract, asymptomatic third molars. There was agreement with the results of Zadick and Levin¹, that young Israeli dentists recommended removal of third molars significantly more often than did Eastern European and South American dentists. In our findings, the group of Brazilian oral surgeons with fewer years of experience recommended removal of third molars significantly more often compared with more experienced surgeons.

Consensus states that extraction of symptomatic and/or diseased mandibular third molars is appropriate treatment9., 11.. However, prophylactic removal of asymptomatic disease-free mandibular third molars is controversial among practitioners, in spite of the clear contraindication for the operation reported in recent literature and by AOOMS, AHA, AMA, ADA for patients with systemic diseases unresponsive to medication9., 12., 13., 14.. Almendros-Marques et al.¹⁵ used a questionnaire addressing the decision to perform, and the degree of confidence in the indication for, prophylactic removal related to 40 asymptomatic impacted lower third molars. The questionnaire was presented to four professionals with different levels of surgical experience. Each professional received information relating to the patients (age and sex, molar inclination and degree of impaction, and the absence of symptomatology). Their results showed no statistically significant differences between residents and trainers in terms of the decision to remove. The management approach adopted by oral surgeons regarding the removal of asymptomatic impacted lower third molars depends upon the perceived risk of complications if such teeth are not removed. Therefore, Almendros-Marques et al. found that the surgical experience does not seem to influence treatment decision, a finding in contrast to that of the present study.

Another finding is that we included Brazilian surgeons who finished their training at different centres in Brazil and abroad. One study, with a similar methodology of survey regarding the management of unerupted mandibular asymptomatic impacted wisdom teeth, reported a significant difference in approach between oral and maxillofacial surgeons in Hong Kong and Glasgow, with the former showing a greater tendency towards extraction of asymptomatic teeth¹⁶.

Third molar/periodontal disease and dental crowding

More than 75% of the surgeons who participated in our survey believe that the third molar can cause periodontal defects of the distal aspect of the second molar or the adjacent tooth, and more than 63% do not believe that the third molar can cause dental crowding.

In 2014, a group from Lithuania¹⁷ published a systematic literature review on the correlation of third molars to the occurrence of lower anterior dental crowding. The authors reviewed 223 articles, published from 1971 to 2011, and selected 21 papers. Their results are similar to ours in that they are rather contradictory: some authors/meetings support the opinion that mandibular third molars cause teeth crowding, whereas others do not. Another survey¹⁸ compared the opinion of oral surgeons and orthodontists on this issue. They found that surgeons were more likely to ‘generally’ or ‘sometimes’ recommend prophylactic removal of mandibular third molars to prevent crowding, whereas orthodontists more often said that they ‘rarely’ or ‘never’ recommend it. In contrast to our results, which did not find a correlation between number of years of experience and this issue, those authors found that the differences in orthodontists’ and oral and maxillofacial surgeons’ beliefs were significantly related to the number of years since graduation. Orthodontists who had graduated more recently were less likely to recommend prophylactic removal of third molars to prevent crowding, and surgeons were more likely to recommend removal if they graduated in the 1970s or 1980s.

In an editorial, Assael¹⁹ advocated the elective removal of all third molars in young adults to mitigate the risks of systemic inflammation and the local progression of emergent periodontal disease. There are data showing that the periodontal status of second molars tends to improve after extraction of third molars that exhibit periodontal pathology²⁰. Therefore, the association between periodontitis and asymptomatic third molars was studied in a trial that included 329 patients, and the results showed that a higher proportion of patients ≥ 25 years of age had pocket depths of ≥ 5 mm on the distal surface of second molars or around third molars compared with patients under 25 years of age (33% vs. 17%, respectively). The distal surfaces of second molars and third molars in the mandible were affected more than those in the maxilla (25% vs. 5%, respectively)⁵. Related to the issue of periodontal problems caused by the third molars, the majority of the responses in our study agreed that these consequences can occur; there were no statistical differences between the study groups.

Classification of third molars

There are several classifications regarding impacted third molars according to the Pell and Gregory scales of position for the occlusal plane (scales A–C) and the ascending ramus of the mandible (scales 1–3)²¹. These scales were eventually regarded as having little value for predicting the degree of extraction difficulty²², mainly because these systems of classification introduce error of interpretation by the observer²³. However, they are nowadays used to compare the prediction of surgical difficulty between groups with different levels of training and experience⁴ as well as to perform demographic population prevalence studies of pattern of tooth impaction²⁴. The Third Molar Classification (TMC)²⁵ has a guideline for the surgical management of impacted third molars, especially in high-risk cases, where often the surgeon is forced to rely mainly on experience and clinical judgment²⁵. Our results showed a division in our study groups regarding use of the TMC, in that almost half use the classification for the management and planning of third molar extraction and the other half did not use any type of rating. As a result of the difficulty mentioned above related to the lack of a universal, reliable, reproducible and easy-to-use method to classify routine third molar cases on a surgical basis, further studies with new third molar classification systems is warranted.

CBCT evaluation of relationship between third molar and mandibular nerve

Because of large variation in inferior alveolar nerve/third molar relationships, a detailed preoperative radiographic assessment is required to identify both the position (buccal, lingual or inferior) and approximation of the mandibular canal (MC) to the third molar to minimise the risk of postoperative dysaesthesia26., 27..

Our results showed that oral surgeons with more years of experience than residents, but fewer than those with postgraduate qualifications, tended to treat deep lower third molar impactions based only on the findings of panoramic radiographs, and would use coronectomy twice as frequently to access deep lower third molars in which there was a close relationship between the root and the inferior alveolar nerve, without resorting to CBCT.

The guidelines published by the European Atomic Energy Community in 2009 state that CBCT is justified when conventional radiographs suggest a close relationship between a mandibular third molar and the inferior dental canal and when a decision to perform surgical removal has been made²⁸. The authors evaluated the risk assessment for MC injury based on panoramic radiography compared with CBCT imaging and concluded that it differed significantly. After review of CBCT images by oral surgeons, significantly more patients were reclassified as having lower risk for MC injury compared with assessments from panoramic radiographs, and they showed that CBCT imaging contributes to more comprehensive surgical planning and risk assessment, which may minimise the risk of MC injury²⁹.

Previous studies have assumed that most clinicians use panoramic radiographs with a series of radiological criteria as an indicator of the relationship, and thus the risk, of postoperative dysaesthesia²⁷. In a Web-based survey of 2,713 Italian dentists (11.9% of answers) concluded that recommendations for CT were proportional to the number of radiographic signs indicating a risk of inferior alveolar nerve injury²⁸. Our results agree with the findings that the majority of Australian oral and maxillofacial surgeons rely upon the results of a panoramic radiograph for the diagnosis of the proximity of lower third molars to the MC, even though many did not consider this image to be the ideal diagnostic tool²⁹.

Use of preoperative NSAIDs in third molar surgery

The acute postoperative pain following surgical extraction of an impacted third molar has been shown to be primarily inflammatory. Accordingly, the use of NSAIDs in this context is appropriate and can be effective. Several types of NSAIDs are used, but almost no information exists on why preference is given to one rather than another. Our findings showed a strong correlation in that the majority of Brazilian oral surgeons follow this recommendation but a consistent number of young surgeons with fewer than 5 years of experience, similarly to Oral surgeons in USA, do not routinely use NSAIDs preoperatively.

An Italian observational, multicenter, prospective survey study³⁰ evaluated the pattern of administration of NSAIDs in patients undergoing surgery for extraction of an impacted third molar. The study also aimed to collect information on the efficacy, onset and duration of the analgesic effect of routinely prescribed NSAIDs and to assess the duration of treatment with these drugs and their tolerability. In their study group of 616 patients, they found that nimesulide was the most commonly prescribed NSAID (68%), followed by diclofenac, ketoprofen and ibuprofen. The results of this study also showed that nimesulide, especially when given before patients started experiencing pain after surgery, was more effective than the other NSAIDs in reducing the severity of pain on the day of surgery, in delaying the time to maximum intensity of pain, in providing complete pain relief and in prolonging the duration of the analgesic effect on the day of surgery.

In this same line of thinking, it has been well documented that systemic corticosteroids result in less swelling and a more positive experience without added risk⁵. However, our results showed that the adoption of this practice is not homogenous between the groups and is not a consensus between the subjects of the same group.

CONCLUSIONS

Even though only 94 of the 1180 meeting attendees answered the questionnaire in a valid manner, the results of the current study reveal that most oral and maxillofacial surgeons behave differently regarding the way they treat third molars clinically. Most treat patients in accordance with the current literature. The number of years of experience and level of training seems to influence the frequency according to which the surgeon decides to use a CBCT to perform an impacted molar procedure, as well as being related to the indications for extraction of asymptomatic third molars.

Acknowledgements

To CAPES/CNPq and Brazilian Army for the Scholarship and Permission to the first author to perform the Research Fellow in the University of Kentucky. Mr David A. Akers from Department of Statistics of University of Kentucky for the statistical analyses. We state that all the authors have viewed and agreed to the submission.

Conflict of Interest

No conflict of interest.