J Oral Maxillofac Surg

61:1436-1448, 2003
Risk Factors Associated With Prolonged
Recovery and Delayed Healing After
Third Molar Surgery
Ceib Phillips, PhD,* Raymond P. White, Jr, DDS, PhD,
Daniel A. Shugars, DDS, PhD, MPH, and Xiaolei Zhou, MS
Purpose: We sought to identify the demographic, oral health, and surgical risk factors associated with
prolonged recovery after third molar surgery using health-related quality of life (HRQOL) and clinical
outcomes.
Patients and Methods: HRQOL responses from patients and clinical outcomes were obtained after
third molar surgery. Criteria were selected for HRQOL outcomes that separated patients with from those
without prolonged recovery. Delayed clinical healing was indicated by a patient having at least 1
postsurgery visit with treatment. Risk assessment models for prolonged HRQOL recovery and delayed
clinical healing were developed using stepwise logistic regression analysis.
Results: We included 547 subjects with HRQOL and clinical outcome data in this analysis. Age, gender,
and occlusal plane position were statistically signicantly associated with prolonged recovery for early
symptoms, oral function, and pain. Recovery for lifestyle was prolonged only if both lower third molars
were below the occlusal plane before surgery. Age, gender, prior symptoms related to the third molars,
and the surgeons perception of difculty were statistically signicant predictors of delayed clinical
recovery.
Conclusions: Certain demographic and oral health conditions available to the surgeon before surgery,
and characteristics of the surgery itself, increase the risk of a prolonged recovery for HRQOL outcomes
and delayed clinical outcomes after third molar surgery.
2003 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 61:1436-1448, 2003
The decision of whether or when to remove third
molars is faced by millions of Americans each year.
1,2
The questions of paramount importance to patients
considering surgery are, If I choose to have the teeth
removed, how long will it be before I will return to
normal? How likely is it that something adverse will
happen?
By reviewing relevant literature, the surgeon
can provide only partial answers to these ques-
tions regarding recovery and clinical complica-
tions.
Several recent reports have focused on recovery
patterns after third molar removal. These studies eval-
uated health-related quality of life (HRQOL) domains;
lifestyle, oral function, pain, and symptoms as re-
ported daily by patients.
3-5
On average, usual lifestyle
activities were resumed by 4 days after surgery and
difculties with oral function were resolved by 5 days.
Pain tended to persist for several more days, but half
of the patients had stopped all pain medications by
postsurgery day 7. Using bivariate analysis, it ap-
peared that females, patients with a surgery time
greater than 30 minutes, and those with all third
molars below the occlusal plane before surgery had
longer recovery periods for at least 6 HRQOL mea-
sures.
3
*Research Professor, Department of Orthodontics, School of
Dentistry, University of North Carolina, Chapel Hill, NC.
Dalton L. McMichael Professor, Department of Oral and Maxil-
lofacial Surgery, School of Dentistry, University of North Carolina,
Chapel Hill, NC.
Professor, Department of Operative Dentistry, School of Den-
tistry, University of North Carolina, Chapel Hill, NC.
Research Assistant, Department of Orthodontics, Chapel Hill,
NC.
This study was supported by the Dental Foundation of North
Carolina, Oral and Maxillofacial Surgery Foundation, and American
Association of Oral and Maxillofacial Surgeons.
Address correspondence and reprint requests to Dr White: De-
partment of Oral and Maxillofacial Surgery, School of Dentistry,
University of North Carolina, Chapel Hill, NC 27599-7450; e-mail:
ray_white@dentistry.unc.edu
2003 American Association of Oral and Maxillofacial Surgeons
0278-2391/03/6112-0010$30.00/0
doi:10.1016/j.joms.2003.08.003
1436
The incidence of clinical complications after the
removal of third molars has been documented primar-
ily from retrospective case series,
6-8
although Bruce et
al
6
reported data collected prospectively, specically
to assess clinical outcomes. Delayed wound healing,
related chiey to localized osteitis or wound infection
at surgery sites, is the most frequently occurring clin-
ical complication, affecting approximately 10% of pa-
tients who have surgery. Sensory nerve dysfunction is
reported less frequently: sensory decit of the inferior
alveolar nerve in less than 5% and the lingual nerve in
less than 2%.
Although this information is helpful, it does not aid
the clinician in predicting which patients presurgery
are at greatest risk for prolonged recovery or clinical
complications after surgery. The rst step in the pro-
cess of identifying high-risk patients is an examination
of individual risk indicators. A framework for identi-
fying and grouping potential risk indicators that may
be related to prolonged recovery or delayed healing is
presented in Figure 1. Examining the relationship
between an indicator and recovery in a simple biva-
riate approach can give an incomplete picture of the
relationship, because it is more likely that a combina-
tion of factors will most efciently distinguish be-
tween patients who are at risk for a prolonged
HRQOL recovery or delayed clinical healing and those
who are not.
This study was designed to develop risk assessment
models to identify the combination of risk factors
associated with prolonged HRQOL recovery or de-
layed clinical healing. The analysis was based on in-
formation obtained from a multicenter prospective
cohort of patients who had third molars removed
between 1997 and 2001. The predictive ability of
these models was also assessed.
Patients and Methods
HRQOL responses and clinical outcomes were ob-
tained from patients after third molar surgery as part
of an institutional review boardapproved prospec-
tive clinical trial, conducted at 9 community practices
and 5 academic clinical centers. Demographic, oral
health, and surgical data were also collected and an-
alyzed to assess the relationship of these characteris-
tics with clinical recovery and recovery as perceived
by the patients.
Enrolled patients were healthy and between the
ages of 14 and 40 years. Inclusion criteria for the
clinical trial dictated that patients would have all 4
third molars removed. Inclusion/exclusion criteria are
identical to those in the clinical trial reported by
White et al.
4
After consenting to participate in the study, and
before removal of all four third molars, baseline data
were recorded. These included demographics (age,
gender, ethnicity), and oral health conditions (prior
symptoms related to third molars and temporoman-
dibular joint [TMJ] symptoms presurgery indicated by
limited opening). Third molar position was deter-
mined from the presurgery panoramic radiograph:
each tooth was designated as at/above or below the
occlusal plane (Table 1).
A standard surgery protocol was used for patients
in the study at each of the clinical centers. It allowed
anesthesia and surgical procedures common to sur-
gery in the United States.
4
On the day of surgery,
details of the procedure were recorded. This included
whether bone was removed from each third molar,
the surgeons assessment of the difculty of surgery
for each third molar, and the duration of the surgery
in minutes. Bone removal, difculty, and length of
surgery were then categorized as described in
Table 1.
On the day of surgery, each patient was given an
HRQOL diary based on the one administered by Con-
rad et al.
3
The patient was instructed to complete 2
pages of the diary each postsurgery day for 14 days.
The diary was designed to assess a patients percep-
tion of recovery in 5 main domains related to the
removal of third molars: pain, lifestyle, oral function,
and early and late onset symptoms (Table 2). Recov-
ery for each HRQOL measure was dened as the
number of days before a patient reported a score of 1
(none) or 2 (little) on the Likert-type scales. At the
end of the 2-week recovery period, patients were
asked to return the completed diary to the data cen-
ter. Data entry was managed as reported by White
et al.
4
A patient was categorized as experiencing pro-
longed HRQOL recovery if, for a given domain, the
length of recovery exceeded a clinically relevant cri-
FIGURE 1. Categories of risk indicators/explanatory variables that
may be related to salient outcomes of third molar removal: prolonged
health-related quality of life recovery (HRQOL) recovery and delayed
clinical healing. (* Explanatory values not assessed in our analysis.)
PHILLIPS ET AL 1437
terion value for any of the measures in the domain
(Table 2). The criterion values were based on the
distribution of recovery times that were reported by
patients in the cohort described by White et al.
4
Criterion values were chosen so that recovery that
exceeded these values would be of clinical concern.
For example, if a patient reported that it required 5
days or more before swelling bothered them little
or none, that patient would be included in the
group with prolonged recovery for early symptoms.
Less than one third of the patients reported recovery
times that exceeded our selected criterion values.
Patients were not required by the protocol to re-
turn for a postsurgery visit but were encouraged to do
so if symptoms worsened after the rst few postsur-
gery days or if the patient wanted a surgeons clinical
assessment of the healing process. If the patient re-
turned for any reason, the presence or absence of
symptoms and any treatment rendered were re-
corded. A delay in healing was dened by a postsur-
gery visit in which at least one of the following treat-
ments occurred: an antibiotic or analgesic was
prescribed; the surgical site was reopened or debrided;
a dressing was placed; or another unspecied treat-
ment was rendered. Delayed clinical healing was cat-
egorized as the number of postsurgery visits with
treatment (Table 2). Given the relatively small num-
ber of patients who had multiple treatment visits, no
attempt was made to differentiate the characteristics
of those who had only one versus those who had
more than one treatment visit.
STATISTICAL ANALYSIS
The bivariate association between the outcomes for
prolonged HRQOL recovery and the risk factors for
prolonged recovery was assessed using the Cochran-
Mantel-Haenszel (CMH) test. Subsequently, model-
building procedures were used to address 2 clinically
Table 1. EXPLANATORY VARIABLES INCLUDED AS POSSIBLE RISK FACTORS RELATED TO PROLONGED RECOVERY
FOR HEALTH-RELATED QUALITY OF LIFE MEASURES AND DELAYED CLINICAL HEALING
Explanatory Variables Categories
Data available before surgery
Demographics
Age (yr) 18, 18 to 21, 21 to 24, 24
Gender Male Female
Race Other Black
Oral health
Prior third molar symptoms Absent Present
Prior temporomandibular joint symptoms Absent Present
Occlusal plane position At most, 1 lower third molar below occlusal plane
Both lower third molars below occlusal plane
Data from surgery
Surgery time (min) 20, 20 to 30, 30 to 40, 40
Bone removal lower third molars From at most, 1 lower third molar
From both lower third molars
Surgeons assessment of total difculty 9, 9 to 12, 12 to 16, 16
Table 2. PROLONGED HEALTH-RELATED QUALITY OF LIFE (HRQOL) RECOVERY AND DELAYED CLINICAL HEALING:
OUTCOME VARIABLES IN THE RISK ASSESSMENT MODELS
Outcomes Description
Prolonged HRQOL recovery Exceeding the criterion number of days until recovery as indicated by little
or no trouble or pain for any one of the items in the domain*
Early symptoms 5 days for swelling, bleeding, nausea, or bruising
Lifestyle 6 days for daily activity, recreation, or social life
Late symptoms 8 days for food collection or bad taste/bad breath
Oral Function 8 days for talking, regular diet, chewing, or mouth opening
Pain 11 days for worst pain or no medication
Delayed clinical recovery/healing Indicated by the number of postsurgery visits with treatment
No visit or visit with no treatment 0
1 visit with treatment 1
1 visit with treatment multiple
*The criterion number of days until recovery were derived from the results reported by White et al.
4
Any treatment indicative of delayed healing, dened as wound dressing, reopening the wound, antibiotic prescription, or other wound
treatment.
1438 PROLONGED RECOVERY AFTER THIRD MOLAR SURGERY
important questions: What information regarding the
likelihood of a prolonged recovery can be given to a
patient at a presurgery consult visit based on data
from the patient? How are the odds of a prolonged
recovery changed by factors encountered at surgery,
such as the necessity of removing bone or the length
of the procedure?
To evolve the most clinically useful information the
following statistical approach was taken.
In the initial model for each domain, only patient data
or patient attributes available presurgery (Demographics
and Oral Health in Fig 1) were included in a logistic
regression model with deviation from the mean param-
eterization (Proc Logistic in PC-SAS, Version 8.02; SAS
Institute, Cary, NC) using a forward selection with the
signicance level to enter set at .05.
9
This parameteriza-
tion approach was used so that the intercept would
represent the average log odds of prolonged recovery
for all patients and the odds ratio for a given presurgery
patient attribute would represent the effect, either in-
creasing or decreasing the likelihood of a prolonged
recovery, of that attribute adjusting for all other factors.
The odds ratios calculated for a presurgery patient at-
tribute such as age or gender would represent the effect
of that attribute on recovery for each of the HRQOL
domains such as lifestyle or pain.
In the next step, statistically signicant presurgery
patient attributes were maintained in the model, and
the data from surgery such as bone removal were
allowed to enter the model using forward selection
with the signicance level to enter set at .05. Devi-
ance tests and Pearson
2
tests were performed to test
the goodness of t of the nal model. Because a
lack of t using only main effects was noted for pain
recovery, all pairwise interactions between patient
attributes were then assessed using a forward selec-
tion in the pain recovery model. The interaction be-
tween gender and surgery time signicantly improved
the t of the pain model and was included in the risk
assessment model for pain.
Accuracy of the statistical models (how likely it was
that the model identied patients who did or did not
have prolonged recovery) was assessed based on the
odds of a prolonged recovery for each HRQOL do-
main. These results were expressed as sensitivity and
specicity scores. These scores reect the accuracy of
data from the patient presurgery and the impact of
adding the data available after surgery in predicting
prolonged HRQOL outcomes.
The same model-building approach using logistic
regression with the signicance level set at .05 was
used to evaluate whether the demographic, oral
health, or surgical variables affected the likelihood of
a delay in clinical healing.
Results
Of the 739 patients in the clinical trial, 109 patients
did not return a completed diary or respond to a tele-
phone query and are not included in this analysis. White
et al
4
reported the characteristics of these patients. An
additional 83 patients did not return a completed diary
but provided estimates of time to recovery for the
HRQOL measures when interviewed by phone. Com-
pared with the 547 patients who did return the diary,
these 83 patients tended to be less educated (17% of
those 19 or older had a college degree versus 33%),
more likely eligible for Medicaid (12% versus 6%), more
likely to be male (55%versus 37%), and more likely to be
black (13% versus 8%). These patients also were ex-
cluded from the multivariate analysis because of the
possible biasing effect of using recall estimates for re-
covery for HRQOL measures rather than diary responses
recorded each day. Figure 2 depicts the ow of patients
through the clinical trial.
Figure 3 illustrates the sample composition by clin-
ical setting, academic versus community practice, and
FIGURE 2. Flow of patients from enrollment to analysis.
FIGURE 3. Distribution of patients (N547) included in the analysis
by the type of practice and the region of the country.
PHILLIPS ET AL 1439
region of the country of the 547 patients with HRQOL
and clinical outcome data included in this analysis.
The characteristics of the patients and data obtained
at surgery were almost identical to those reported by
White et al.
4
The percentage of the patients who exceeded the
criterion established for each of the HRQOL domains
is presented in Figure 4. Sixty-one percent of the
subjects reported a prolonged recovery in at least 1 of
the 5 HRQOL domains; 25% in only 1 of the domains;
12% in 2; 11% in 3; 7% in 4; and 5% in all 5. The
distributions for HRQOL recovery of the 547 patients
from our analysis mirror the distributions for recovery
of the 630 patients reported by White et al.
4
The bivariate relationships between prolonged
HRQOL recovery and the demographic, oral health
behavior, and surgical risk indicators evaluated in this
study are given in Tables 3 and 4. For example, only
17% of patients 18 years old or younger compared
with 35% of those over 24 years old reported that
early symptom recovery took 5 or more days. Recov-
ery from early symptoms such as swelling and nausea
took 5 or more days for 35% of the females but only
21% of the males.
Data available from patients presurgery were used
as explanatory variables in the initial risk assessment
model for each HRQOL domain (Table 5). Note that
FIGURE 4. Percent of patients who did or did not experience pro-
longed recovery as dened by the criterion value in days set for each
health-related quality of life recovery (HRQOL) domain.
Table 3. PROLONGED HEALTH-RELATED QUALITY OF LIFE (HRQOL) RECOVERY. A COMPARISON BY BIVARIATE
ANALYSIS OF THE PERCENTAGES OF PATIENTS IN EACH DEMOGRAPHIC AND ORAL HEALTH CATEGORY THAT
HAD A PROLONGED HRQOL RECOVERY
Explanatory Variable:
Data available before surgery
Early
Symptoms
(5 days)
Lifestyle
(6 days)
Late
Symptoms
(8 days)
Oral
Function
(8 days)
Pain
(11 days)
% P % P % P % P % P
Demographics
Age (yr) .001 .05 .01 .0002 .0001
18 17 21 8 18 20
18 to 21 31 29 18 28 28
21 to 24 35 27 20 37 47
24 35 32 20 39 42
Gender .001 .13 .70 .003 .01
Male 21 24 16 23 28
Female 35 30 17 35 38
Ethnicity .11 .85 .36 .74 .85
White, other 29 28 16 31 34
Black 40 27 21 29 36
Oral health
Occlusal Position .04 .05 .31 .17 .23
2 lower third molars below 25 22 14 27 31
Both lower third molars below 33 30 18 33 36
Prior third molar symptoms .92 .32 .08 .48 .24
No 30 29 13 32 32
Yes 30 26 19 30 36
Prior TM symptoms .63 .05 .07 .02 .78
No 29 27 15 29 34
Yes 33 42 27 48 36
NOTE. Within each explanatory variable above, the P value represents the statistical difference among the distribution of patients who
exceeded the criterion for prolonged recovery. For example, more female patients exceeded the criterion for delayed recovery for early
symptoms, 5 days, than males. The difference is statistically signicant, P .001. If a patient had temporomandibular symptoms before
surgery, that patient was more likely to exceed the criterion for recovery for oral function, 8 days, than a patient with no previous
temporomandibular symptoms, P .02.
1440 PROLONGED RECOVERY AFTER THIRD MOLAR SURGERY
age, gender, and occlusal plane position were statis-
tically signicantly associated with prolonged recov-
ery for early symptoms, oral function, and pain. Re-
covery for lifestyle was only related to occlusal plane
position. Late symptom recovery was related only to
age. Race, prior third molar symptoms, or TMJ symp-
toms (limited mouth opening before surgery) did not
contribute to the explanation of prolonged recovery
in any of the HRQOL outcomes. This was true even
after adjusting for the effects of the other attributes of
the patient available before surgery.
If data obtained at surgery are added to the risk
assessment models, bone removal from at least both
lower third molars and/or the length of the procedure
are statistically signicant predictors of the occur-
rence of prolonged recovery for early symptoms, life-
style, oral function, and pain recovery (Table 6). The
surgeons assessment of the difculty of the surgery
was not signicantly related to prolonged recovery in
any of the 5 HRQOL domains.
How clinically important are these statistically sig-
nicant outcomes? After adjusting for other factors,
the odds of an older patient (24 years) experiencing
a prolonged recovery is approximately 3 or 4 times
that of a patient 18 years old or younger for early
symptoms, late symptoms, oral function, and pain
recovery. Patients with both lower third molars be-
low the occlusal plane were about 1.5 to 2 times as
likely to experience prolonged recovery from early
symptoms, pain, lifestyle, and oral functions (Tables
5, 6). Bone removal on both mandibular third molars
increased the odds of delayed recovery for lifestyle
and oral function.
Females had twice the odds of males of a delayed
recovery in oral function and early symptoms.
The length of the surgery affected the likelihood of
a prolonged pain recovery differently for males and
females. For surgery times longer than 40 minutes,
the odds of a prolonged pain recovery for females was
3.7 times that for males; for 30- to 40-minute proce-
dures, 2.1; for 20- to 30-minute procedures, 1.7. For
20 minutes or less of surgery, females were less likely
(odds ratio 0.67) than males to report prolonged
pain recovery (Table 6). For females, the odds ratio of
prolonged pain recovery for a surgery longer than 40
minutes compared with a surgery time of 20 minutes
or less was 3.58 (95% condence interval [CI], 1.87,
6.83) while for males, the odds ratio was only 0.64
(95% CI, 0.25, 1.62) (data not reported in Table 6).
Patients who had multiple risk factors (older than
24 years, female, both lower third molars below the
occlusal plane, and a longer surgical procedure, 40
minutes) had approximately 12 times the odds of
experiencing a prolonged recovery in early symptoms
(95% CI, 4.8, 30.5) and 9 times (95% CI, 3.7, 22.1) the
odds for delayed pain recovery compared with those
patients with none of these characteristics. If both
lower third molars are below the occlusal plane, bone
is removed from lower third molars, and the surgical
procedure is long (40 minutes), the odds of a pro-
longed recovery for lifestyle are increased by 3.8
times (95% CI, 1.9, 7.6). And female patients, who are
Table 4. PROLONGED HEALTH-RELATED QUALITY OF LIFE (HRQOL) RECOVERY: A COMPARISON BY BIVARIATE
ANALYSIS OF THE PERCENTAGES OF PATIENTS IN EACH SURGICAL CATEGORY THAT HAD A PROLONGED HRQOL
RECOVERY
Explanatory Variable:
Data available after surgery
Early
Symptoms
(5 days)
Lifestyle
(6 days)
Late
Symptoms
(8 days)
Oral Function
(8 days)
Pain
(11 days)
% P % P % P % P % P
Surgical
Bone removal .41 .01 .45 .004 .29
2 lower third molars 27 21 15 24 31
Both lower third molars 31 31 17 35 36
Length of procedure (min) .0004 .02 .01 .0002 .001
20 23 26 13 22 25
20 to 30 25 20 12 28 35
30 to 40 33 31 23 39 39
40 41 35 21 40 43
Assessment of difculty .69 .88 .52 .43 .51
9 30 24 17 27 33
9 to 12 28 32 20 36 32
12 to 16 27 30 12 28 38
16 34 24 17 34 34
NOTE. Within each explanatory variable, such as bone removal, the P value represents the statistical difference among the distribution of
patients who exceeded the criterion for prolonged recovery. For example, more patients exceeded the criterion for recovery of oral function,
8 days, if they had bone removal on both lower third molars. The difference is statistically signicant, P 0.004. An increase in the
surgeons assessment of difculty was not statistically signicantly associated with prolonged recovery for any HRQOL category.
PHILLIPS ET AL 1441
over 24 years old, have both lower third molars below
the occlusal plane, and have bone removed on both
lower third molars, have 13.9 times (95% CI, 5.5,
35.2) the odds of a longer recovery in oral function.
The utility of these models in predicting which
patients will experience prolonged recovery can ini-
tially be evaluated by comparing those patients pre-
dicted by the model to experience a prolonged recov-
ery with the actual outcomes (Table 7). For example,
175 patients experienced prolonged pain recovery
and the combined patient and surgery attributes
model predicted 112 correctly for a sensitivity of 64%.
The specicity of the model was 61%, which means
that 204 of the 336 patients who did not report
prolonged pain recovery were correctly identied.
Combining the information from surgery with the
patient attributes available before surgery changed
the odds ratios of the impact of patient attributes only
slightly (Table 6) but did improve the specicity of
the risk models (Table 7). These data allow the clini-
cian to counsel a patient before surgery about out-
comes with only a slight chance that an event at
surgery would drastically alter what was advised pre-
surgery. The odds ratio and 95% CIs for the odds ratio
when all explanatory or predictor data obtained from
patients presurgery and data collected at surgery are
included in the model, whether or not the attribute is
statistically signicant, are provided in Table 8 for
future comparisons with other similar studies.
Seventy-eight percent of the patients either did not
return for a postsurgery visit (n 181) or did not
have treatment as dened in Table 2 during the visit
(n 244). Fourteen percent had 1 postsurgery visit
with treatment (n 79), and 8% (n 43) had treat-
ment at more than 1 postsurgery visit. The percentage
of subjects in each of the demographic, oral health,
and surgical categories who had no or at least 1
postsurgery visit with treatment is given in Table 9.
Age, gender, prior symptoms related to the third
molars, and the surgeons perception of difculty
were statistically signicant predictors of delayed clin-
ical healing (Table 9). After adjusting for other factors,
the odds of a patient having delayed healing, whose
surgery was perceived as being quite difcult (16 of
28), was 7 times that of a patient whose surgical
difculty was perceived as minimal (9). Females and
patients who had had prior third molar symptoms had
approximately twice the odds of delayed healing.
Relative to patients 18 or younger, patients over 24
years old and those between 18 and 21 years had
approximately 1.5 times the odds of delayed healing.
Patients who had multiple risk factors (older than 24
years, female, prior symptoms, and a difcult proce-
dure) had approximately 15.34 times (95% CI, 5.41,
43.52) the odds of requiring treatment during at least
1 visit compared with patients with none of these
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1442 PROLONGED RECOVERY AFTER THIRD MOLAR SURGERY
Table 6. PROLONGED HEALTH-RELATED QUALITY OF LIFE RECOVERY: STATISTICALLY SIGNIFICANT ODDS RATIOS (ORs) AND CONFIDENCE INTERVALS (CIs)
FROM THE MULTIVARIATE LOGISTIC REGRESSION MODELS WHEN PATIENT AND SURGICAL ATTRIBUTES ARE COMBINED (P S)
Early Symptoms Lifestyle Late Symptoms Oral Function Pain
OR (P S) 95% CI OR (P S) 95% CI OR (P S) 95% CI OR (P S) 95% CI OR (P S) 95% CI
Data available before surgery
Demographics
Age (yr)
18 to 21 vs 18 2.12 1.16, 3.87 NS 2.60 1.19, 5.72 2.17 1.18, 4.01 1.77 0.97, 3.21
21 to 24 vs 18 2.65 1.41, 4.96 NS 3.07 1.38, 6.81 3.96 2.10, 7.47 3.99 2.17, 7.33
24 vs 18 3.08 1.67, 5.66 NS 2.90 1.35, 6.23 4.80 2.61, 8.83 4.17 2.29, 7.59
Female 2.17 1.40, 3.37 NS NS 1.84 1.20, 2.83 *A, B, C, D
Black NS NS NS NS NS
Oral health
Both lower third molars below
occlusal plane 1.90 1.22, 2.95 1.36 0.87, 2.12 NS 1.49 0.95, 2.32 1.56 1.02, 2.38
Prior third molar symptom NS NS NS NS NS
Prior temporomandibular
symptom NS NS NS NS NS
Data from surgery
Surgical
Bone removal both lower third
molars NS 1.65 1.04, 2.63 NS 2.17 1.37, 3.43 NS
Length of surgery (min)
20 to 30 vs 20 1.02 0.58, 1.78 0.60 0.34, 1.07 NS NS *A, B
30 to 40 vs 20 1.52 0.85, 2.74 1.19 0.67, 2.11 NS NS *C
40 vs 20 1.97 1.16, 3.35 1.52 0.91, 2.56 NS NS *D
Surgeons assessment of
difculty NS NS NS NS NS
Abbreviation: NS, the explanatory variable was not a statistically signicant predictor of prolonged recovery.
*Surgery-Gender interaction: A, surgery time 20 min: odds of a female having a prolonged recovery is 0.67 that of males; B, surgery time 20 min-30 min: females have 1.67 times odds of
males; C, surgery time 30 min-40 min: females have 2.08 times the odds of males; D, surgery time 40 min: females have 3.68 times the odds of males.
P
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characteristics. The sensitivity of the model was
73.9%, and the specicity 59.2%.
Discussion
The following describes the limitations of the ap-
plicability of our data, the rationale for our selected
explanatory/predictor variables and outcomes, and
how our ndings might alter clinicians perceptions
of previously published outcome data following third
molar surgery.
The sample of 547 patients represents a reasonably
diverse population of patients having third molar sur-
gery in the United States. Both academic and commu-
nity practices are represented as are all geographic
regions excepting the southwest. Potential limitations
on the applicability or generalizability of our ndings
do exist. Few Hispanic patients were studied and only
9% of patients were older than 30 years. Inclusion of
centers with a larger proportion of minority patients
or over sampling of minorities might be considered in
future studies. One hundred ninety-two patients of
the 739 enrolled patients were not included in this
analysis either because the diary was not returned or
because recovery estimates were obtained by tele-
phone interview rather than daily report. These pa-
tients were more likely to be male, to be black, and to
use tobacco. The effect of these limitations cannot be
quantied directly.
Although the odds ratios for risk factors for delayed
recovery displayed in Tables 5 and 6 should not be
applied to a specic patient, the data we report give
surgeons and patients a general idea about what does
affect recovery. We caution that these odds ratios are
not directly comparable to data from other studies,
even if a similar statistical approach were used. The
estimates would be different if the criterion values
dening prolonged recovery were changed or if the
set of possible risk factors were changed. Certainly,
the particular conguration of variables selected as
statistically signicant would change if other risk fac-
tors such as presurgery anxiety were available for
inclusion in the model or if the level of signicance
was changed.
Even with a sample size of 547, only 42 blacks were
enrolled; only half were older than 21 years. These
numbers are not adequate to examine whether com-
bining race and age may impact recovery. Likewise,
the relative impact of the use of tobacco on recovery
and its possible interaction with other explanatory
variables cannot be assessed. Current data on tobacco
use was only available for 319 patients and smoking
was not considered in the risk assessment because of
the missing data. Of those who answered, only 16%
reported current tobacco use. Given the age distribu-
tion of our patients this is likely under-reported.
A clinician might identify a patient at risk for de-
layed HRQOL or clinical recovery at the presurgery
consultation or after the surgical procedure. We be-
lieve that the criterion values chosen for delayed
recovery in our analysis for HRQOL outcomes are
clinically relevant. Patients whose recovery is pre-
dicted to be in the worst third of those having surgery
might require additional counseling and more atten-
tive postsurgery care than patients not in this group.
In addition, special measures to improve recovery for
patients having third molar surgery should be targeted
rst to this higher risk group.
Because conditions related to wound healing after
third molar surgery are the most common reason for
delayed clinical recovery, we chose the criterion of
any treatment at a postsurgery visit related to wound
healing to represent a delay in clinical recovery. Mu-
honen et al
10
used a similar criterion. Only 67% of the
547 patients providing recovery data returned for a
postsurgery visit. No additional clinical information
was available from the 33% of patients who did not
return. The absence of these data may potentially bias
the treatment estimates presented here. If the nonre-
turning patients experienced clinical problems but
Table 7. PROLONGED HEALTH RELATED QUALITY OF LIFE RECOVERY: SENSITIVITIES AND SPECIFICITIES FROM THE
LOGISTIC REGRESSION MODEL WITH PATIENT ATTRIBUTES PRESURGERY (P) ONLY AND THE COMBINED PATIENT
AND SURGICAL ATTRIBUTES (P S) MODEL
Patient Attributes Early Symptoms Lifestyle Late Symptoms Oral Function Pain
P only
Sensitivity 0.64 0.68 0.88 0.68 0.66
Specicity 0.57 0.42 0.28 0.58 0.58
Area under receiver operating
characteristic curve 0.67 0.55 0.59 0.66 0.67
Combined P S
Sensitivity 0.62 0.62 0.63 0.64
Specicity 0.64 0.60 0.58 0.61
Area under receiver operating
characteristic curve 0.69 0.62 0.69 0.69
1444 PROLONGED RECOVERY AFTER THIRD MOLAR SURGERY
Table 8. ODDS RATIO (OR) ESTIMATES AND 95% CONFIDENCE INTERVALS (CIs) FOR MAIN EFFECTS MODEL WITH ALL RISK FACTORS INCLUDED
Early Symptoms Lifestyle Late Symptoms Oral Function Pain
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Age (yr)
18 to 21 vs 18 2.21 1.19, 4.10 1.17 0.94, 3.11 2.4 1.07, 5.39 2.09 1.11, 3.93 1.77 0.97, 3.22
21 to 24 vs 18 2.75 1.44, 5.27 1.77 0.93, 3.38 2.9 1.26, 6.69 3.78 1.95, 7.34 3.92 2.10, 7.31
24 vs 18 3.08 1.64, 5.79 2.15 1.16, 3.98 2.82 1.24, 6.38 4.82 2.53, 9.19 3.93 2.14, 7.19
Female 2.12 1.36, 3.30 1.35 0.88, 2.08 1.0 0.6, 1.66 1.92 1.24, 2.98 1.64 1.09, 2.49
Black 1.81 0.88, 3.74 0.88 0.40, 1.97 1.09 0.44, 2.69 0.65 0.29, 1.45 0.82 0.39, 1.70
Both lower third molars
below occlusal plane 2.00 1.25, 3.21 1.43 0.90, 2.29 1.57 0.90, 2.73 1.34 0.84, 2.13 1.45 0.93, 2.26
Prior third molar
symptoms 0.83 0.54, 1.27 0.70 0.46, 1.07 1.16 0.70, 1.95 0.70 0.45, 1.07 1.09 0.72, 1.64
Prior temporomandibular
symptoms 1.36 0.59, 3.10 1.66 0.74, 3.75 1.77 0.73, 4.30 2.22 0.98, 5.03 1.03 0.45, 2.34
Bone removal both
lower third molars 1.13 0.68, 1.87 1.98 1.17, 3.33 1.23 0.68, 2.24 2.09 1.25, 3.50 1.25 0.77, 2.04
Length surgery (min)
20 to 30 vs 20 0.99 0.56, 1.75 0.6 0.33, 1.08 0.87 0.42, 1.81 1.13 0.64, 2.0 1.55 0.91, 2.65
30 to 40 vs 20 1.40 0.76, 2.57 1.16 0.64, 2.13 1.62 0.79, 3.3 1.68 0.92, 3.09 1.61 0.89, 2.90
40 vs 20 1.95 1.11, 3.41 1.46 0.84, 2.53 1.67 0.85, 3.29 1.84 1.04, 3.25 1.96 1.14, 3.39
Assessment of difculty
9 to 12 vs 9 0.72 0.40, 1.31 1.11 0.61, 2.01 1.01 0.51, 2.01 1.25 0.69, 2.26 0.85 0.48, 1.52
12 to 16 vs 9 0.63 0.34, 1.16 0.87 0.47, 1.62 0.61 0.29, 1.29 0.79 0.42, 1.48 1.16 0.65, 2.08
16 vs 9 0.85 0.44, 1.65 0.66 0.33, 1.30 0.87 0.40, 1.87 1.11 0.57, 2.15 0.93 0.49, 1.76
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chose to see their general dentist or to self-treat, then
the estimates would be too low. On the other hand, if
patients did not return because no clinical problems
were experienced, the estimates presented would be
accurate.
It is commonly thought that older patients are at
greater risk for complications and delayed recovery
following third molar surgery. Over 2 decades ago,
Bruce et al
6
reported that increased age was associ-
ated with an increase in clinical complications after
removal of a single mandibular third molar below the
occlusal plane. That report reinforced the clinical
impressions of surgeons performing third molar sur-
gery; increased age leads to more clinical problems
after surgery including an increased incidence of lo-
calized osteitis and delayed wound healing. The mes-
sage has spread to the extent that many health pro-
fessionals and potential patients seem to believe that
increased age greatly impacts recovery negatively af-
ter third molar surgery. A closer examination of the
data from Bruce reveals that the older patients in his
sample had more surgery than the younger patients.
Those above 35 years of age required a mean surgery
time of 18 minutes for removal of 1 third molar
compared with 8 minutes for patients below 25 years.
Similarly, above 35 years of age, 85% of patients had
bone removal and the third molar sectioned com-
pared with 62% of patients below 25 years old. Bruce
also commented that patients in his oldest age group
had more horizontally positioned third molars fully
Table 9. DELAYED CLINICAL HEALING: A COMPARISON OF THE PERCENTAGES OF PATIENTS IN EACH
DEMOGRAPHIC, ORAL HEALTH, AND SURGICAL CATEGORY WHO HAD NO POSTSURGERY VISIT WITH
TREATMENT OR WHO HAD AT LEAST ONE POSTSURGERY VISIT WITH TREATMENT
No Postsurgery
Treatment
One or More
Postsurgery
Treatment Odds Ratio
95% Condence
Interval
Data available before surgery
Demographics
Age (yr)
18 77% 23%
18 to 21 76% 24% 18 to 21 vs 18 1.25 0.68, 2.29
21 to 24 84% 16% 21 to 24 vs 18 0.68 0.34, 1.36
24 74% 26% 24 vs 18 1.68 0.93, 3.05
Gender
Male 83% 17%
Female 75% 25% 1.71 1.07, 2.74
Ethnicity
White, other 78% 22%
Black 69% 31% NS
Oral health
Occlusal position
2 Lower third molars below 82% 18%
Both lower third molars below 74% 26% NS
Prior third molar symptoms
No 82% 18%
Yes 74% 26% 1.96 1.24, 3.11
Prior temporomandibular symptoms
No 77% 23%
Yes 88% 12% NS
Data from surgery
Bone removal
2 Lower third molars 87% 13%
Both lower third molars 72% 28% NS
Length of procedure (min)
20 minutes 78% 22% NS
20 to 30 minutes 79% 21% NS
30 to 40 minutes 78% 22% NS
40 minutes 75% 25% NS
Assessment of difculty
9 91% 9%
9 to 12 77% 23% 9 to 12 vs 9 3.66 1.77, 7.54
12 to 16 70% 30% 12 to 16 vs 9 5.87 2.95, 11.66
16 69% 31% 16 vs 9 7.20 3.49, 14.81
Abbreviation: NS, the explanatory variable was not a statistically signicant predictor of prolonged recovery.
1446 PROLONGED RECOVERY AFTER THIRD MOLAR SURGERY
covered by bone, 27%, compared with 9% in the
youngest age group. In most instances, more bone
must be removed for horizontally impacted third mo-
lars than for most third molars in different anatomic
positions. Unfortunately, the study by Bruce did not
control for other risk factors.
In our study, after adjustment for other risk factors,
age was associated with a delayed recovery for clini-
cal outcomes, a postsurgery visit with treatment, but
the pattern was not a simple one (Table 9). Subjects
between 21 and 24 were the least likely to have a
postsurgery visit with treatment (only 16%). A higher
proportion (26%) of those over 24 years old had at
least one postsurgery visit with treatment, but this
proportion was not substantially different than for
those 18 to 21 years (24%). A surgeons estimate of
increased difculty with the surgical procedure pre-
dicted a delayed clinical recovery for our cohort of
patients. This seems to be consistent with the data
reported by Bruce et al as discussed earlier.
6
Clinical recovery was delayed, requiring at least
one postsurgery visit with treatment, if a patient had
third molar symptoms before surgery. This delay
could be related to microbial colonization of patho-
gens at the surgical site resulting in symptoms before
surgery and a subsequent delay in wound healing.
McGrath et al
11
reported that quality of life improved
compared with presurgery, after third molar removal
in patients symptomatic before surgery. They attrib-
uted the presurgery symptoms in the patients studied
with those of pericoronitis. If these patients can be
considered at higher risk, targeted interventions for
these patients, such as topical antimicrobial rinse be-
fore surgery, might improve recovery. The topic de-
serves further study in prospective clinical trials.
After controlling for other risk factors including
gender, third molar position, bone removal, and sur-
gery time, our data did show an association between
age and delayed recovery for HRQOL outcomes. The
odds of a patient older than 24 taking more than 8
days to report no or little problem with oral function
or more than 11 days to no or little pain, was approx-
imately 4 times the odds of a patient 18 years old or
younger. Perhaps our data on HRQOL and clinical
outcomes will assist clinicians and others in putting
the inuence of age in a proper perspective. Patients
older than 40 years of age were not enrolled in our
clinical trial; recovery in older patients deserves fur-
ther study.
Conrad et al
3
indicated that a surgery time of 30
minutes or longer prolonged recovery for almost all
HRQOL measures studied. Our data also show an
association between an incremental increase in sur-
gery time above the median of 30 minutes and de-
layed clinical recovery, but the difference is minimal
(Table 6). Surgery time above 40 minutes increased
the odds of a prolonged recovery for early symptoms
and lifestyle. A longer surgery substantially increased
the odds of females experiencing a delayed recovery
from pain. Although bone removal from lower third
molars statistically predicted delayed recovery for life-
style and oral function, bone removal and the length
of surgery are certainly related. In fact, both the av-
erage surgical time (33 versus 28 minutes) and the
perception of difculty (14 versus 9) were signi-
cantly different (P .001) if patients had bone re-
moved from at least the 2 lower third molars.
In adolescent patients, the extent of surgery alone
may not be an accurate predictor of recovery for
HRQOL outcomes. Gidron et al
12
studied the impact
of the extent of surgery including bone removal and
the surgeons estimate of difculty, and psychosocial
factors on recovery for mouth opening, a proxy for
physical recovery, on postsurgery days 4 and 7, in 67
patients between 13 and 20 years of age. The extent
of surgery was associated with delayed recovery for
mouth opening, but was less a factor than psychoso-
cial predictors. For example, these younger patients
expectations about a rapid or delayed recovery and
parent pampering such as relief from assigned
chores, outweighed the difculty of surgery in pre-
dicting return to presurgery mouth opening. No asso-
ciation existed between extent of surgery and recov-
ery for lifestyle measures in the adolescent patients
studied. Psychosocial factors, parents attitudes about
recovery as projected to their children having sur-
gery, were the greatest predictors of rapid or delayed
recovery for usual daily routine and social life.
George et al
13
studied the combined impact of
surgical trauma and presurgical psychological factors
on recovery after third molar surgery in 38 patients
who were somewhat older, with an age range of 17 to
32 years. Both the extent of surgical trauma and the
level of presurgery anxiety were signicant and equal
predictors of delayed recovery for daily activity. No
psychosocial data were included in our statistical
models (Fig 1). Clinicians should remember that de-
mographic, oral health, and surgical explanatory vari-
ables are not sufcient to account completely for
recovery after third molar surgery. The psychosocial
issues deserve further study particularly in patients
considered at risk for delayed recovery.
Conrad et al
3
reported that females experienced
prolonged recovery for pain measures, talking, sleep-
ing, and chewing. Among our cohort of patients,
females had higher odds of prolonged recovery than
males for oral function and early symptoms, and sub-
stantially higher odds for delayed pain recovery if
length of surgery was longer than average. Gender
alone was associated with delayed clinical recovery,
having a postsurgery visit with treatment, in our
study. The impact of gender on health and HRQOL
PHILLIPS ET AL 1447
was the focus of a recent report from the Institute of
Medicine and a review by Inglehart.
14,15
Both encour-
age more emphasis on gender differences in health
issues. Recovery from third molar surgery, a relatively
short ambulatory procedure, could be a model for
better dening gender differences.
TMJ symptoms before surgery were not associated
with delayed recovery for clinical outcomes in our
study. Only 33 patients had TMJ symptoms before
surgery in our sample, and only 4 of them received
treatment during a postsurgery visit. Such a small
number provides very little power to detect differ-
ences.
The logistic regression analysis used in this study is
helpful in examining hypothesized relationships be-
tween the set of demographic, clinical, and surgical
risk factors and HRQOL recovery and in exploring
combinations of these variables that may moderate or
amplify the effect. The exploration of these more
complicated associations derived from patients in this
clinical trial serves 2 purposes: alerting clinicians to
characteristics and procedural events that likely
would delay recovery, altering the information that
might be provided to patients; and identifying those
events at surgery related to delayed recovery that may
be modied by changes in clinical practice or new
techniques.
To further test the application of the data reported
here, additional patients having third molar surgery at
several clinical sites not involved in generating data
reported in this clinical trial are being studied, and the
predicted outcomes will be compared with the pa-
tients actual recovery. Preliminary studies also are in
progress assessing the impact of interventions such as
the use of preventive doses of antibiotics or cortico-
steroids in patients expected to be at higher risk for
delayed recovery.
In summary, certain demographic and oral health
conditions available to the surgeon before surgery,
and data from the surgery itself were predictably
associated with prolonged recovery for HRQOL do-
mains (early symptoms, lifestyle, late symptoms, oral
function, pain) and delayed clinical outcomes (at least
one postsurgery visit with treatment) after third molar
surgery.
These data provide surgeons with additional, clini-
cally important information, useful in counseling pa-
tients about recovery after surgery. In addition, iden-
tifying patients at higher risk for prolonged recovery
will allow investigators to test interventions to facili-
tate recovery in these higher risk patients.
Acknowledgments
The authors offer a special thanks to the surgeons and their
patients who volunteered to provide data for this analysis. The
authors wish to thank Debora Price, Lyna Rogers, and Terri Horton
for assistance in managing data for this project.
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1448 PROLONGED RECOVERY AFTER THIRD MOLAR SURGERY