|Year : 2020 | Volume
| Issue : 2 | Page : 65-69
Medical profile and medication consumption of patients presenting for mandibular third molar surgery: Experience in a Saudi Arabian sub-population
Ramat Oyebunmi Braimah1, Dawood Ali-Alsuliman1, Hakeem Olatunde Agbaje2, Yahyah Alsalah1, Harit Kanwar Sharma1, Nahal Mamdoh Alsawas1
1 Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Medical Village Complex, Shurfa, Najran, KSA
2 Department of Orthodontics, International Medical Complex, Shurfa, Najran, KSA
|Date of Submission||03-Oct-2019|
|Date of Decision||29-May-2020|
|Date of Acceptance||21-Jul-2020|
|Date of Web Publication||23-Sep-2020|
Ramat Oyebunmi Braimah
Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran
Source of Support: None, Conflict of Interest: None
Introduction: Extraction of the impacted third molar is one of the most common minor oral surgical procedures carried out in oral surgery clinic. For the medically compromised, the sequelae and possible complications of third molar surgery can be enormous if such medical conditions are not properly identified and managed adequately. Methodology: Patients presenting for mandibular third molar surgery in the department of oral and maxillofacial surgery, specialty dental center, with medical conditions were recruited into the study from 2015 to 2018. Third molar not indicated for surgical removal were excluded. Data such demographics of patient presenting for third molar extractions, indications for third molar removal, pattern of third molar impaction, medical conditions, and medication consumptions were collected from the electronic medical records. Results: A total of 1024 patients presented for mandibular third molar extraction during the study out of which 123 patients were medically compromised with the prevalence of 12%. There were 32 (26%) male and 91 (74%) female with a M:F = 1:2.8. The age ranged from 17 to 69 years with mean (age ± standard deviation) 31.4 ± 9.6 years. Hypertension/diabetes and hypothyroidism constitute the majority of the compromised condition (35 [28.5%] each) closely followed by hyperthyroidism 23 (18.7%), while hypertension alone constitute the least (1 [0.8%]) case. Conclusion: All patients presenting for the removal of impacted third molar should be investigated for medical conditions by first taking a good and complete medical history to avoid conditions that can put the life of patients under serious risk.
Keywords: Comorbidity, diabetes, hypertension, mandibular third molar
|How to cite this article:|
Braimah RO, Ali-Alsuliman D, Agbaje HO, Alsalah Y, Sharma HK, Alsawas NM. Medical profile and medication consumption of patients presenting for mandibular third molar surgery: Experience in a Saudi Arabian sub-population. Dent Med Res 2020;8:65-9
|How to cite this URL:|
Braimah RO, Ali-Alsuliman D, Agbaje HO, Alsalah Y, Sharma HK, Alsawas NM. Medical profile and medication consumption of patients presenting for mandibular third molar surgery: Experience in a Saudi Arabian sub-population. Dent Med Res [serial online] 2020 [cited 2020 Oct 27];8:65-9. Available from: https://www.dmrjournal.org/text.asp?2020/8/2/65/295864
| Introduction|| |
As the world population is growing at an exponential rate coupled with improved access to medical care, more number of elderly people with systemic medical conditions that can affect oral health and dental treatment will also continue to rise. The dental management of these medically compromised elderly patients can be problematic in terms of oral complications, dental therapy, and emergency care. Similarly, younger age group with systemic medical conditions will continue to rise with the rising population. It is therefore important for dental clinicians to understand the potential complications that can occur as a consequence of dental treatment of a medically compromised patient and when pretreatment or posttreatment medication or emergency care is indicated.
Interaction between medical and dental practitioners about patients with medical conditions requiring dental treatment is very important for the overall patient's management. Studies have shown that such interaction rarely occurs and this may be due to lack of appreciation by doctors of the medical risks to certain patients undergoing dental treatment.
Extraction of the impacted third molar is one of the most common minor oral surgical procedures carried out in oral surgery. The most common postoperative complications following third molar removal are alveolar osteitis and surgical site infection. Others are permanent nerve damage, pain, trismus, swelling, and difficulty in swallowing resulting in poor quality of life. For the medically compromised, the sequelae and possible complications of third molar extraction can be enormous if such medical conditions are not properly identified and managed adequately.
Literature search did not reveal any study reporting on medical profile and medication consumptions in patients presenting for surgical extraction of impacted third molars in Saudi Arabia. The main objective, therefore, is to report the prevalence of patients with medical conditions and medication consumptions presenting for the removal of impacted mandibular third molar in Najran, a South-western province of the Kingdom of Saudi Arabia.
| Methodology|| |
All patients presenting for the extraction of mandibular third molars at the Regional Specialty Dental Center, Najran, Saudi Arabia, form January 2015 to December 2018 were retrospectively reviewed using the computerized medical records. The regional dental center is a major referral dental specialty hospital with over 40 specialized clinics managed by specialists and consultants in various fields of dentistry and serving the entire region with over 500,000 citizens. Ethical approval for the study was received from the institutions review board. Third molar teeth not indicated for surgical removal were excluded from the study. Data such demographics of patient presenting for third molar extractions, indications for third molar removal, pattern of third molar impaction, medical conditions, and medication consumptions were collected from the electronic medical records.
The prevalence was measured by comparing the number of patients having medical conditions with the total number of patients presenting for third molar extractions. The data were processed and analyzed using IBM SPSS software version 25 for IOS (IBM Corp., Armonk, NY, USA). Descriptive statistics were generated as part of the data analysis, and Chi-square was used to compare the relationship among the different variables (gender, age group, and medical conditions). The level of statistical significance was set at P ≤ 0.05.
| Results|| |
A total of 1024 patients presented for mandibular third molar extraction during the study out of which 123 patients were medically compromised with the prevalence of 12%. There were 32 (26%) male and 91 (74%) female [Figure 1] with a M:F = 1:2.8. The age ranged from 17 to 69 years with mean (age ± standard deviation) 31.4 ± 9.6 years. [Figure 2] shows that majority of the patients that presented for third molar extraction was in the age group of 21–30 years.
|Figure 1: Pie chart showing gender distribution of patients with medical conditions|
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|Figure 2: Bar chart showing age group distribution according to gender of patients|
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Hypertension/diabetes and hypothyroidism constitute the majority of the compromised condition (35 [28.5%] each) closely followed by hyperthyroidism 23 (18.7%), while hypertension alone constitute the least (1 [0.8%]) [Table 1]. The age group 41–50 years constitute the highest number of patients that were medically compromised presenting for mandibular third extraction (39 [31.7%]) while the least was seen in the age group of 61–70 years (2 [1.6%]) [Table 2]. Hypertensive and diabetic patients were frequently associated with vertical impaction (21.1%), while hypothyroidism patients had more mesioangular impaction (23.6%). Other distributions are shown in [Table 3].
|Table 1: Distributions of medical conditions according to gender of patients|
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|Table 2: Distributions of medical conditions according to the age group of patients|
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|Table 3: Distributions of medical conditions according to angulation of impacted teethxs|
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Caries (84 [68.3%]) was the main indication for third molar extraction in the group followed by pericoronitis (26 [21.1]). Other distributions are summarized in [Table 4]. [Table 5] shows the medication consumption of the medically compromised presenting for third molar removal. It will be observed that all patients with hypertension were on regular aspirin and mostly on amlodipine (calcium channel blocker), while most of the diabetics were on oral hypoglycemics.
|Table 4: Distributions of medical conditions according to indication for extraction|
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|Table 5: Distribution of medication consumption of medically compromised patients|
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| Discussion|| |
A multidisciplinary approach is required when patients with medically compromised situations present for dental procedures especially minor oral surgical procedures because of the complexity involved in their management. Elaborate medical history is the first step in the management of patients with medical conditions followed by fully understanding the significance of the disease in terms of dental management.,, For third molar extractions with its sequelae and possible complications, the dental clinician needs to understand the potential complications that can occur as a consequence of the procedure on medically compromised patient and when pretreatment or posttreatment medication or emergency care is indicated.
Female predilection was observed in this study with 91 (74.0%) cases of the medically compromised presenting for the surgical removal of mandibular third molar. Several studies have reported female gender penchant in patients with medical conditions reporting for dental procedures., This has been attributed to better health seeking behavior among the female folks. Form the present study, a prevalence rate of 12% of medically compromised was observed in patients presenting for the extraction of impacted third molars with the age group of 41–50 years constituting the highest frequency. The reason for this low rate of medically compromised in third molar surgery is because most of the symptomatic cases requiring surgical removal are seen in young patients. Although the third molar extraction is common in the age group of 21–30 years, which was also observed in the current study, when older patients present for this procedure, the clinician should expect some medical conditions which should be properly investigated to avoid emergency situations in the clinic not equipped for handling such emergencies. It is also interesting to note that in the current study, about 51 (41.5%) patients in the younger age group of 20–30 years and 31–40 years have medical conditions most of which is epilepsy, hyperthyroidism, and hypothyroidism. It has been reported that there is a higher tendency for dental visits among the young population with medical conditions.
Relationship between medical condition and angulation of impaction has not been studied, however we observed in our series that mesioangular impactions was frequently associated with hypothyroidism, while vertical impaction was associated more with the combination of hypertensive and diabetic patient. This aspect needs more research to ascertain the relationship between medical conditions and angulation of third molar impaction.
In our study, hypertension and diabetes constitute the highest frequency of medical morbidity the older patients. This current finding corroborated previous studies on the medical conditions in dental patients., However, other studies have reported allergy as the most common medical condition in dental patients., Hypertension, as a comorbid condition was only involved in 1 (0.8%) patient in the age group of 61–70 years. This essential hypertension is common in this age group. In addition, all these patients were on daily low-dose aspirin (80 mg) as a prophylaxis against heart attacks and stroke. When properly controlled, dental treatment can be done without any medical risk. In such controlled patients, our protocol involved using local anesthesia without adrenaline and blood pressure taken before and after the third molar extraction. Furthermore, we reduced anxiety by keeping instruments and equipment away from the patient's view. In order to prevent orthostatic hypotension, sudden shifting of the dental chair was avoided. These precautions have been reported in the literature. Furthermore, all the patients on low-dose aspirin were instructed to stop the medications for 5 days prior to presentation to prevent prolonged bleeding following the third molar removal.
Diabetes which is a dysfunction in blood sugar regulation was observed in 13 (10.6%) patients as a sole comorbid condition. Among these 13 patients, 9 (69.2%) patients fell within the type I diabetic mellitus (T1DM) and have been on insulin medications. Type 1 diabetes mellitus is one of the most common endocrine metabolic disorders affecting children and adolescence across the world. In Saudi Arabia, 35,000 children and adolescents suffer from T1DM, which makes Saudi Arabia rank the 8th in terms of numbers of TIDM patients and 4th country in the world in terms of the incidence rate (33.5/100,000 individuals)., In general, in the kingdom, there is sharp increase in the incidence of both T1DM and T2DM. With respect to third molar extractions, surgery should be scheduled in the morning when endogenous corticosteroids levels are highest and patient is able to tolerate stress very well. This protocol was observed in all our patients. In addition, random blood sugar measurements were carried out before surgery and postoperative antibiotics were given for all the patients to prevent risk of infection since these individuals are more prone to immune system dysfunctions (as lazy leukocyte syndrome) and poor wound healing. When the medical conditions of both hypertension and diabetes occur together in an individual, the health challenges and burden is also enormous. Both comorbid conditions were observed in 35 (28.5%) patients in older age group. Precautions for both medical conditions (hypertension and diabetes) were followed for all our patients with the combined condition.
Epilepsy is a common neurological disorder in Saudi Arabia, with a prevalence of 6.54/1000. This high prevalence rate shows that dentists should be aware of the dental implications of this medical condition. In these group of patients, efforts should be made to reduce triggering factors especially stress and anxiety. If the condition is uncontrolled, patients should be referred to the physicians for control. In our patients that were controlled and on regular medications, they were schedule for the third molar extraction in the morning before seeing other patients. In addition, instruments and equipment were not displaced in front of patient and dental light are kept away from the eyes as much as possible to prevent triggering any seizure.
There are very few reliable studies that show the prevalence by thyroid diseases in Saudi Arabia. In Riyadh and Al-bahah regions of the kingdom, the prevalence was reported to be high especially in females., The most common thyroid diseases reported in these two regions where hypothyroidism. In Al-bahah region, which is in the same region as the current study, a prevalence rate of 42.8% of the female patients was having hypothyroidism while only 3.17% had hyperthyroidism. In the Riyadh region, 15.5% of the female examined had hypothyroidism while none had hyperthyroidism. With these two studies from the Kingdom of Saudi Arabia, it shows that thyroid disease is rampant. In the current study, 47.2% thyroid disease (28.5% hypothyroidism and 18.7% hyperthyroidism) was reported with male to female ratio of 1:2.6. This has validated reports of thyroid disease in the kingdom. Outside the kingdom, similar reports have been published in Great Britain and the United States of America about the prevalence of thyroid diseases in these countries.
| Conclusion|| |
All patients presenting for the removal of impacted third molar should be investigated for medical conditions by first taking a good and complete medical history to avoid conditions that will put the life of patient under serious risk. With high prevalence of medical conditions in the kingdom, dentists should be aware that more patients with these conditions will present for dental procedure. All medically compromised except for infectious conditions (hepatitis, human immunodeficiency virus/acquired immune deficiency syndrome, tuberculosis, etc.,) should be scheduled in the morning for third molar extractions with minimal display of instruments and equipment to reduce stress and anxiety. Furthermore, they should be placed on prophylactic antibiotics to prevent surgical site infection which is a common complication following third molar extractions in infected environments.
The authors are grateful to Miss Fatima Fegaihy, of the Dental Nursing Department, Najran Specialty Regional Dental Center, Shurfa, the Kingdom of Saudi Arabia, for her assistance during the data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]