Evaluation of Knowledge and Perception of the Third Molar Extraction Procedure Among Patients in the Eastern Province, Saudi Arabia: A Cross-Sectional Study

Introduction

Third molar extraction is one of the most frequently performed oral surgical procedures worldwide.¹ Tooth impaction is defined as the inability of the tooth to erupt in a full functional position in the oral cavity.² Clinical and radiographical evaluations could predict the degree of difficulty of third molar extraction preoperatively.³ The patient’s advanced age, depth, angulation of the impaction, and proximity to the inferior alveolar canal, maxillary sinus, and infratemporal fossa contribute to the extraction difficulty.⁴ Multiple theories elucidated the rationale behind third molar impactions: the discrepancy between the dental arch circumference and the sum of the mesiodistal width of the teeth, the attrition theory, and the discrepancy between dental and skeletal maturation.⁵

The eruption of third molars usually begins at the age of 17 to approximately 21 years.⁵ However, it is estimated that third molars fail to erupt in 25% of the population.⁶ Third molars are indicated for extraction if they include one or more of the following: developmental cysts, infections, recurrent episodes of pericoronitis, a periodontal disease affecting the adjacent teeth, interfering with adjacent teeth eruption, non-restorable or pulpal involvement, and for orthodontic or orthognathic considerations.⁷

There are some factors to be taken into consideration during decision-making for third molar extraction, such as the tooth position, proximity to vital structures, limited mouth opening, ankylosis, history of radiation therapy, medications such as a bisphosphonate, as well as overall patient health.⁸ In wisdom tooth extraction, According to Seymour et al., post-operative discomfort, pain, swelling, and bleeding are commonly associated with the procedure.⁹ A post-operative symptoms severity (PoSSe) scale was developed to measure the discomfort and severity of symptoms following third molar extraction, and it was shown that 97% of patients suffered from post-operative pain.¹⁰

Operative factors have little bearing on patients’ quality of life (QOL).¹¹ In aiming to improve the patient’s experience, multiple studies investigated the effect of medications on pain management studies). Monaco G. et al. concluded that antibiotic prophylaxis effectively prevented wound infection and postoperative pain in young patients after removing lower third molars.⁶ Another study reported that Cryotherapy effectively decreased postoperative swelling, pain, and limitation of mouth opening, improving patients’ QOL.¹² An additional study showed a high association between patients’ anxiety and post-operative pain. Patient awareness of the procedure could minimize anxiety about wisdom teeth extraction.¹³ The author suggested conducting a separate consultation with an Oral and Maxillo-Facial Surgeon (OMFS) to make the procedure more comprehensible to the patient.

On the other hand, other studies reported that separate wisdom teeth consultation did not reduce the level of anxiety.¹⁴ However, adequate awareness about the procedure is required for all patients, especially anxious patients.¹⁵ It has been shown that patients with more inquiries are more anxious than others, and women are more anxious than men.¹⁶

Overall, the true perception of patients about the preoperative, intraoperative, and postoperative nature of wisdom teeth extraction could positively impact their experience with wisdom teeth extraction.¹⁷ The clinician must know that all patients require sufficient information regarding the procedure. It’s essential to guide surgeons to optimize the surgical procedure, increase patient comfort, and decrease postoperative risks.¹⁸ Brasileiro B et al. assessed patients’ preoperative, intraoperative, and postoperative perception prior to third molar extraction. They found that 28.4% of respondents misunderstood the type of medications received preoperatively, some of the patients expressed concerns about the anesthesia technique and discomfort post-operatively, 23.9% and 17.9% respectively, and the most asked question was “Will all my teeth be removed at once?” in 59.6%.¹¹ Comparing patients with previous extraction experience and those without experience, patients with no experience had more questions and misconceptions than the ones with prior experience.¹⁸

Due to the gap of knowledge in the literature regarding the nature of third molar extractions in relation to knowledge and misconception, this cross-sectional observational study aimed to investigate patients’ knowledge and misconceptions about third molar extraction among patients visiting Imam Abdulrahman bin Faisal University Dental Hospital in the Eastern province of Saudi Arabia.

Methods

Results

In total, 409 patients had third molar extractions, of which 266 (65%) were male and 35% were female. Most patients were Saudi nationals (89%), and 46% were between 18 and 24 years old. Table 1 shows the demographic characteristics of the patients who had third molar removal surgery. As per history with the extraction, 45% had previous wisdom tooth extraction experience, whereas 55% had no previous dental surgical expertise.

In this study, the most common indication for wisdom teeth extraction was the abnormal path of tooth eruption (24%), followed by pain or decayed teeth (19%). Figure 1 summarizes all other indications of wisdom teeth extraction. Patients were divided into two groups: previous experience with the extraction and no previous extraction, and a comparison was done with knowledge items. Quantitatively, no significant difference was found between the groups with knowledge about the extraction (p-0.901). A qualitative comparison is presented in Table 2. Patients with no previous history were found to be more aware of the correct time for third molar eruption, 27%, vs. patients with a previous history of extraction, 19%, and the association was also statistically significant (p-0.046). Correct knowledge level about items, extraction of the third molar is mandatory (67% vs. 73%), a phobia about pain and actual pain feeling (54% vs. 51%), and smoking after the extraction delayed the healing process (49% vs 50%) was almost same between both groups without any statistical significance. Additionally, the misconception about anesthetic technique and extraction of more than 1 extraction was found to be highest in both groups with no statistically significant difference.

Figure 1. Indications for wisdom teeth extraction in this study.

Table 3 presents the patients’ perceptions with and without previous experience with extraction. Crowded teeth can be aligned by extraction; Group 2 (previous experience) was more confident than Group 1 (no experience) (42% vs. 37% respectively) but not significantly different. Regarding the medication before the surgery, group 2 was statistically higher with the right perception (47% vs. 25%) (p-0.001). Other perceptions were not statistically different between groups 1 and 2. Analgesics were the most common choice among the other medications mentioned (34%) for post-operative medicines Figure 2. The majority (43%) thought all mentioned medication should be taken after the surgery.

Figure 2. Patients knowledge about the post-operative medication in this study.

Multiple logistic regression showed no statistically significant factors associated with the knowledge level Table 4. The chance of correct knowledge about the eruption time was 1.489 times higher among patients with previous experience. Similarly, those who have prior experience know better (OR = 1.230) about the pain and anxiety relationship during the surgery. For the rest of the items, the knowledge was not as expected from the experienced group.

Discussion

The present study aimed to investigate the knowledge and misconceptions of patients about third molar extraction. Out of 409 total responses, 65% of those who attended the dental hospital seeking different dental treatments were males. Compared to females, a study showed that males attended more dental clinics for third molar extraction.¹⁹ However, a study reported a higher female-to-male ratio regarding third molar extraction.²⁰ This kind of discrepancy in demographic factors can be found in many studies. However, regarding the third molar extraction procedure, a systematic review study highlighted females presented with 14% more than males in terms of having at least one missing third molar.²¹ In our study, the age group between 18 and 24 years was predominant among the participants. Generally, this is the eruption time of third molars.²² A previous study showed that patients undergoing third molar extraction were noted in the age group of 21 to 30 years.²³

Abnormal eruption in the current study was the most common chosen factor, which indicated third molar extraction at 24%, followed by caries and pain at 19%. Additionally, a result revealed by a local study in Saudi Arabia which investigated the prevalence of impaction and the reasons for extraction found that the most common indication for extraction of the third molar was the asymptomatic and prophylactic reason (66.8%), and the symptomatic was (33.2%).²⁴ In contrast to our findings, Dhafar et al. reported that the caries of third molars was the first indication(42.3%), followed by the eruption abnormalities and prophylactic reason (39.2%).²⁵ This comes in agreement with another study by Adeyemo et al. on caries factor.²⁶ However, many factors and reasons can lead to third molar extraction, as discussed previously by Steed MB et al.²⁷

Our findings compared the misconceptions of patients with and without a previous history of third molar extraction, which resulted in more correct answers from participants in the group with previous extraction history. This agrees with a previous study that evaluated the pre-operative perceptions of patients who underwent third molar extraction and found low misconception among groups with a previous history of third molar extraction.¹¹

Patients with and without a previous history of third molar extraction showed no significant difference in knowledge. Both groups presented high percentages of correct answers about the third molar age eruption. Moreover, it was mentioned in the previous study that eruption starts at 17 years old in the oral cavity²⁸ regarding whether extraction of the third molar is mandatory; for this answer, as reported, the decision will be according to the presence of disease and if the tooth asymptomatic or not.²⁹ Our study showed a misconception about whether it is doable to extract the four wisdoms simultaneously; this can be done locally or under general anesthesia according to the case difficulties. Many variables can be addressed to evaluate the case, either patient-related or third molar-related.³ Misconceptions regarding the anesthesia technique were noticed in the current study. Generally, the same technique can be used to extract other molars besides different techniques.^30,31

There was no significant difference (p-0.325) between the groups when it came to relationship between feeling pain and anxiety/phobia. Additionally, anxiety was reported to be presented with more pain to the patient.³² However, another study evaluated separate consultation appointments prior to third molar extraction as it was effective according to the patients.³³ Besides that, his relationship was also found in another study in which they reported a significant relationship between less post-operative pain and verbal information about the extraction steps.³⁴ We believe different ways to reduce anxiety should be considered before third molar extraction. For example, a significant reduction in anxiety levels was reported after using the audiovisual method.³⁵

Participants showed no statistical significance in both groups regarding whether smoking after extraction delayed the healing process (49% vs 50%). Such answers give us an overview of the lack of knowledge about this fact. In addition, oral hygiene should be maintained after oral surgery to avoid any source of infection and promote healing. Furthermore, a review study reported that tobacco can affect the surgical site after tooth extraction.³⁶

The knowledge of patients about post-operative medications in our study illustrated that all three analgesics, antibiotics, and mouthwashes should be taken after the third molar extraction (43%); patients answered analgesics only (34%), followed by antibiotics (15%), then mouthwashes (8%). It was reported that analgesics are the most effective medications for pain relief after dental extraction.³⁷ The role of the antibiotic in oral surgery to prevent post-operative infection was statistically significance.,³⁸ but it is not required for simple extraction.³⁹

As per our knowledge no previous study was conducted in Saudi Arabia similar to our study. However, some limitations can be addressed in our study, such as the fact that the participants were only from one dental hospital in the eastern province of Saudi Arabia, convenience sample, the study design and patients are not aware of their correct answers after filling out the survey. Thus, further investigation should be done to increase the patients’ knowledge and awareness regarding perioperative and postoperative third molar extraction. We recommend further research to evaluate the pre- and post-knowledge scores and use educational material to assess the improvement level.

Conclusions

Patients with previous experience presented greater confidence regarding third molar extraction, although this difference was not statistically significant. Additionally, patients with previous experience demonstrated a better understanding of pain and anxiety relationship during the surgery which may assist the surgeon in determining the need for sedation prior to surgery

Ethics and consent

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Imam Abdulrahman Bin Faisal University (IRB-2022-02-397) (approval date: 20^th of October, 2022). Written informed consent was obtained from all participants included in the current study.