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UNIVERSITY OF NAIROBI

SYMPTOMS AND PATTERNS OF IMPACTION OF THIRD

MOLARS AMONG PATIENTS ATTENDING THE

UNIVERSITY OF NAIROBI DENTAL HOSPITAL.

Dr. J.F. Onyango BDS (Nairobi) MSc FDS, RCS (England),

Department of Oral and Maxillofacial Surgery,

University Dental Hospital.

Kennedy Otieno Ndege BDS III,

Faculty of Dental Sciences,

University of Nairobi,

P.O. Box 19676,

Nairobi.

SUPERVISORS

Dr. Loise Gathece, BDS, MPH (Nairobi),

Department of Periodontology,

Community and Preventive Dentistry

A community dentistry research proposal submitted in partial fulfillment for the

award of a Bachelor of Dental Surgery degree at the University of Nairobi.

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TABLE OF CONTENTS

LIST OF ABBREVIATIONS 3SUMMARy 4INTRODUCTION 5LITERATlJRE REVIEW 6

1.1 Research statement : 81.2 Study justification 81.3 Objectives 9

1.3.1 Main objectives 91.3.2 Specific objectives 9

1.4 Hypotheses 91.5 Variables 9

2.0 METHODOLOGy 102.1 Study area 102.2 Study population 102.3 Inclusion criteria 102.4 Exclusion criteria 102.5 Study design 102.6 Sample size 102.7 Sampling process 11

3.0 DATA COLLECTION INSTRUMENTS AND TECHNIQUES 113.1Method 113.2 Instruments 113.3 Data analysis 113.4 Data presentation 113.5 Limitations 113.6 Expected benefits 123.7 Ethical consideration 12

3.8 BUDGET 134.0 REFERENCES 145.0 APPENDIX 17

5.2 Data CoIlectionForrn 17

LIST OF ABBREVIATIONS

1. M.P.H.- Masters in Public Health

2. M.Sc- Masters in Science

3. F.D.S. - Faculty of Dental Sciences

4. R.C.S. - Royal College of Surgeons

5. B.D.S. - Bachelor of Dental Surgery

6. UoN - University of Nairobi

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SUMMARY

Dental impaction is a condition in which there is obstruction of teeth to attain

normal functional position. It affects the last teeth to erupt in the dental arch

mostly the third molars, canines and pre-molars. It occurs In every race

worldwide. Its presence can initiate pain or sensitivity and complications may

arise as a result of its presence in the dental arch. The impacted teeth can be as a

result of lack of space in the dental arch complicated by the fact that the third

molar is the last tooth to erupt. The epidemiology of the third molar impaction

has been found to vary in different geographical locations.

This will be a descriptive cross-sectional study aimed at evaluating the symptoms

and patterns of occurrence of third molar impaction among a cohort of 138

conveniently selected patients attending the University of Nairobi Dental

Hospital.

The data will be collected from the patients' recorded clinical History, clinical

examination findings and their records of the investigations done such as

periapical radiographs, orthopantomograms and histo-pathological results in cases

of cysts and turnours. Clinical examination forms will be used to record

information collected from the study. Data collected will include age, sex, other

associated lesions, angulations and symptoms involving the impacted third molar.

This data shall be presented in form of bars, tables and pie charts. Date generated

will be entered in a computer and analyzed with SPSS version.

The information collected from this study may be used by oral health care

providers in planning for management of patients who present with impacted third

molars and associated conditions.

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INTRODUCTION

Teeth may become impacted when they fail to erupt or develop into

proper functional position. Impacted teeth may therefore be non-

functional, abnormal or pathological (Waite et al 1998, Raynolds et al

1998). The causes of impacted third molars may include inadequate

space in the dental arch to accommodate the erupted teeth. Teeth that

fail to attain a functional position may be pathological and should be

considered for removal. The indications for removal include pain,

pericoronitis, periodontal disease, caries, cysts and tumors. These

impacted third molars can also create orthodontic anomalies, making

orthodontic treatment difficult (Pell et al 1942, Guralnick et al 1984).

Studies by Kugelgerg et al 1992 revealed that cellulitis, osteomyelitis

and abscesses could also occur as a result of an impacted third molar.

The third molar is the common tooth to become impacted. Among

Caucasians in the United Kingdom, 65% of males with average age of

19 and half years have between one to four embedded third molars

equally divided between the four quadrants of the dental arches. Most

impactions however occur in the mandibular arch. (Kelley et al 1965,

Key et al 1965).

Several studies have been done on impacted third molars in developed

countries where several millions of dollars are spent annually on the

management of impacted third molars (Flick et al, 1999). In fact it is

regarded as the most common oral surgery performed (Waite et aI,

1998). Although only a few studies have been published, none was

done on the symptoms and patterns of impaction of third molars in

Kenya.

Despite the importance of this condition in the dental profession, little

study has been done about its epidemiology among the Kenyan

population. The aim of this study is therefore to analyze the pattern,

symptoms and pathology associated with impacted third molars based

on a examination of patients' records and radiographs. Information on

pattern of impaction shall include age, sex, site of impaction and other

associated lesions.

s

LITERATURE REVIEW

Dental impactions occur when there is prevention of complete eruption into

normal functional position of one tooth by another. The third molar continues to

generate more controversy concerning eruption pattern and pathologic sequel than

any other tooth in the oral cavity (Herbert et al 1994, Mecek et al 1994) Despite

racial variation in eruption sequence, it is universally accepted that the third

molar is the last tooth to erupt. This late eruption explains the fact that third

molars are the most frequently impacted teeth (Odunsanya et al, 1984).

Several theories have been suggested to explain the aetiology of third molar

impaction and this include hereditary factors, lack of sufficient eruption force for

third molars, reduced growth at the posterior region of the mandible and

insufficient mesial movement of the dentition of modern man due to lack of

interproximal attrition (Lytle et al, 1993). The theory of phylogenetic regression

of the jaw size seems to be the most widely accepted (Odunsanya et al, 1984). The

most common patterns of impaction include mesioangular impaction, horizontal,

distoangular and vertical impactions (Pyrin et al 1987). The common lesions that

are associated with these impacted third molars include pericoronitis

(inflammation of the operculum surrounding an unerupted tooth), caries, bone

resorption, cysts e.g. follicular cysts, and mural neoplasia e.g. odontogenic

myxoma (Guralnick et a l, 1984).

Third molar impaction is a common disorder in countries with high standard of

living. Many surveys (Foose et al, 1957. Thomas et al, 1957. Tate et al, 1994)

have shown that the incidence of this disorder attains high levels in industrialized

countries of Europe and North America. In contrast surveys carried out in

communities with a simple mode of life have in general shown a lower incidence

third molar impaction. Figures ranging from 9.5% to 25% have been reported for

its occurrence in different populations (Mead et al, 1930, Kramer et al, 1970).

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Studies have been done on different aspects of third molar impactions. A study by

Goldberg et al 1982 in USA noted that 46.4 % of patients had caries of the

impacted third molar. This he noted could be attributed to the fact that that

impacted teeth create a stagnant site and these are more vulnerable to caries.

Another study by Guralnick et al 1984 showed that proximal caries occur as a

result of impaction of a third molar due to difficulty in cleaning of the proximal

areas that contact with the second molar. This, he noted occurred in 95% of third

molars that had impacted mesioangularly.

Goldberg et al 1982 in USA also noted that 17.3% of impacted third molars were

associated with pericoronitis. In contrast Howe et al 1965, observed that 58.5% of

patients (n= 1355) had pericoronitis. A retrospective study of third molar surgery

by Saheeb et al, 2001 at the University of Benin Dental Teaching Hospital found

out that 32.2% of his patients had pericoronitis. It was also noted that there is a

difference in presentation in the nature and type of pain associated with

pericoronitis and caries. While caries cause excruciating pain, pericoronitis cause

pain, which is intermittent and often dull. Punwurtikon et al 1999 reported that

where symptoms exist, pain was common to erupted and unerupted third molars.

Pain was common in disto-angular impaction - 68.29%of all the cases had pain

while 31.17% were asymptomatic and disease free.

Saheeb et al, 2001 also noted that 63.8% of his patients had mesioangular

impaction (n=142). Orhan Guven and Ahmet Kaskin, 2000 also found out that the

incidence of cysts and tumors around impacted third molars in a study on Turkish

volunteers was 3.1 % (n=9994), cysts accounting for 2.31 % and tumors accounting

for 0.79%. Of the tumors, they also noted that 0.77% were benign tumors while

0.02% was malignant.

Ameet Shah 1989, a BDS student, on a study on the incidence of impacted

mandibular third molars at Kenyatta National Hospital found out that 1. 58% of

patients had periodontitis associated with the impacted third molars

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1.1 Research statement

Several studies have shown that impactions are mostly seen in young adults

between the ages 18 - 25. The presence of an impaction is a risk factor to a

myriad of dental disease e.g. canes, periodontal disease, abscesses.

It is of utmost significance that this condition is known and given urgent attention

in the dental profession.

Dental professionals in Kenya are very few and their getting knowledged on the

current information regarding this condition in Kenya and also Patients becoming

enlightened about the present context regarding this condition will go a long way

in improving oral health awareness and improving oral health care in Kenya.

1.2 Study justification

Impaction is a significant oral and maxillofacial pathology that mainly affects the

third molar. A study by Knights et al 1992 in USA revealed that surgery of the

third molar accounts to 80% of all the work undertaken by oral surgeons. The

occurrence of third molar impaction can initiate pain or mal-alignment of teeth in

a patient

Several studies have been done about the patterns of impacted third molars among

Caucasians especially in the United States and Europe; however, there IS very

little publicized data to compare the Kenyan situation to these studies.

By determining the patterns of third molar impactions, dental professional may

use this study to plan for treatments of patients with impacted third molars and

maxillofacial surgeons will have an overview of the characteristics of these

patients.

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1.3.2 Specific objectives

1. To assess the age distribution

2. To determine the sexual preponderance

3. To determine the common arch and site of impaction.

4. To determine the angulations that involves impacted third molar.

5. To determine the oral pathologies that are associated with impacted third

molars.

6. To compare the symptoms with the underlying pathology associated with

impacted third molars

1.3 Objectives

1.3.1 Main objectives

To determine the patterns and symptoms of third molar impactions III patients

attending the University of Nairobi Dental Hospital.

1.4 Hypotheses

1 The mandible is the predominant arch of impaction.

2 There is no sexual preponderance in the impactions of the third molar.

1.5 Variables

Variables Measurement

Independent variables

• Age Number of years

• Sex Whether male or female

Dependent variables

• Arch Whether mandibular or maxillary arch

• Other lesions Presence or absence of caries, cysts,

tumors, pericoronitis or other swellings

and infections

• Impacted third molars Whether present or not

• Associated symptom Whether symptomatic or not

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2.0 METHODOLOGY

2.1 Study area

The study will be conducted at the University Dental Hospital that is a teaching

hospital for general dental practitioners and Oral Surgeons. It is a referral

hospital for oral and maxillofacial cases in Kenya and is located about 3kms from

Nairobi, which is the capital city of Kenya.

2.2 Study population

Study involving patients whom had presented at the oral diagnosis and oral

surgery clinics with cases of impacted third molars.

2.3 Inclusion criteria

All patients.with impacted third molars.

2.4 Exclusion criteria

Patients' without impacted third molars.

2.5 Study design

This will be a descriptive cross sectional study.

2.6 Sample size

A sample size of 138 was obtained using the formula

Sample size (1) = Zn P (I-P)

C2Use of 10% as proportion = p (Goldberg et al, 1982)

A confidence level of 1- confidence level = 1-0.95 = 0.05

Corresponding z value for 95% confidence level is 1.96

=1.962 * 0.10(1-0.1)0.052

=138.2976

=138

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2.7 Sampling process

Convenient sampling will be used, as cases and the radiographic findings will be recorded as they

are documented in the patients' records.

3.0 DATACOLLECTION INSTRUMENTS AND TECHNIQUES

3.1 Method

The history, clinical examination and investigative records of the patients will be

studied and information concerning age, sex, presence of an impaction and other

lesions and symptoms recorded in data collection form

3.2 Instruments

Data collection form will be used to collect quantitative information about the

pattern of the third molar impaction on the patients recorded files.

3.3 Data analysis

The investigative forms will be coded and the data processed with statistical

package for social sciences (SPSS) 12.0 (SPSS include Chicago, Illinois USA).

Descriptive analysis will be used to describe the data.

Cross tabulation will be used to compare different variables.

3.4 Data presentation

The data will be presented in form of tables, charts and bar graphs.

3.5 Limitations

1. Financial constraint as the project is self-funded and, due to limited resources because the

investigator is a student.

2. Inadequate time to collect information because the investigator is a student who has other

obligations to undertake.

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3.6 Expected benefits

1. Clinicians in oral and maxillofacial surgery may use this report as a guideline

on expected clinical findings and the sociodemographic distribution of this

condition and thereby plan for the management of their patients.

2. Report may be used the government in its preparation of an oral health policy

paper of the republic of Kenya.

3. Patients will know more about the expected symptoms and characteristics of

this condition and thus be able to seek earlier treatment if affected by the

condition.

4. Report to be used in partial fulfillment for a Bachelor of Dental Surgery

Degree at the University of Nairobi.

3.7 Ethical consideration

Proposal will be submitted to the University of Nairobi Ethics and research and

standards for approval. Permission will be sought from the relevant authorities.

The purpose of the study, the expected benefits and risks will be explained to the

authorities. The information obtained will be treated with confidentiality.

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3.8 BUDGET

Activities/Items Quantity Kshs.

Stationary1. Pens 10 @ 10 100

2. Writing materials 1 Rim @ 300 300

3. Ruler 1 @ 20 20

Sub-Total 420/=

Literature search1. Internet browsing 1/= per minute 600/=

2. Library books 20/= per book 100/=

Printing and Typing

1. Proposal typing 20 pages @ 20 4001=

2. Printing 20 pages @ 10 200/=

3. Investigative forms 250 @10 2,500/=

Photocopying

1. Proposal 20 pages @ 4 80/=

Binding 1 copy 50/=

TOTAL 4,350/=

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4.0 REFERENCES

1) Flick M.G. Third molar controversy as a public health policy issue. J. Oral

Maxilofac Surg. 1995; 57; 438-44

2) Foose D.H., Thomas D.H. Third molar impaction. Br Dent J. 1957; 102; 174-6

3) Goldberg M.N, Nemarach. A. N, Marco WP. The impacted third molar referral

patterns, patient compliance and surgical requirements. J. AM. Dental Assos

1983; 107; 439- 441

4) Grand HG: Prevalence of impacted teeth and associated pathology in middle

aged and older adults, 1995: 114- 132

5) Herbert M.H., Mecek M.D. Perception of the need for removal of impacted

third molar by general dentist and oral & maxillofacial surgeons. J. Oral

Maxillofac Surg. 1994; 52; 681-6

6) Howe G.L. The management of impacted mandibular third molars, minor oral

surgery. Bristol, John Wright and sons ltd. 1965: 301-314

7) Killey H.C and Kay L. W, The impacted wisdom tooth. Edinburg, Livingston

PW 1965: 110-114.

8) Kramer R.M.; Incidence. Survey at Harleim Hospital. Oral Surg Oral Med Oral

Pathol; 1970; 231-4

9) Kulgelgerg C.F. Third molar surgery. Oral and maxillofacial infections, 1992;

III: 9-16

10) Lytle J.J. Aetiology and indication for management of impacted teeth. Oral

maxillofac Surg. Clin N. America; 1993; 5; 63-75

11) Mead S.V. Incidence of impacted teeth. Int. J. Orthodont; 1930; 16; 885-890

12) Nitzan DW Tan Osela A. Pericoronitis: a reappraisal of its clinical and

microbiological aspects. J. Oral maxillofacial surgery 1985: 89-90

13) Odunsanya S. A. Third molar impaction among Nigerian youths.

Odontostomatol. Trop 1984; 2; 76-83

14) Orhan Guven, Ahmet Kaskin, Incidence of cysts and tumors in a center in

Istanbul, Turkey. International journal of oral and maxillofacial surgery,

2000, Vol. 29; 2; 131-135

14

15

15) Osborne et al 1985. Journal of oral and maxillofacial surgery treated with

confidentiality 1985: 89-94.

16) Osborne TP: A prospective study of complications related to third molar

surgery. I Oral. Maxllofacial surgeryPathol1988: 17-113-17

17) Pell P.G. The prophylactic removal of third molar and its epidemiology 1942;

31-36

18) Punwutikorn I. & Waikakul A. Symptoms of unerupted third molar. Oral Surg

Oral Med Oral Pathol Oral Rad io l and Endodontics, 1999; 87; 305-10

19) Pyrin BR. Third molar surgery: current concepts and controversies. Part 1,

Oral Health; 1: 28-35

20) Saheeb B.D.O. Mandibular third Molar Surgery, Journal of Surgicl Research,

2001;3;2

21) Tate te. Impactions; observe or treat. Wv Dent I. 1994; 68; 19-23

22) Waite P.O. & Raynold R.R. Surgical management of impacted third molars.

Seminar on orthodontic; 1998; 4; 113-2

23) Walter Guralnich. Third molar surgery. British Dental Journal 1984 156: 389-

394.

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SYMPTOMS AND PATTERN OF TIDRD MOLAR IMPACTION AMONG

PATIENTS ATTENDING THE UNIVERSITY OF NAIROBI DENTAL

HOSPITAL

5.2 DATA COLLECTION FORM.,

DATE OF PRESENTATION .

NAME OF PATIENT FILE

No AGE .

PUT ATICK WHERE APPLICABLE

1. Site of Impaction

I ~ Maxillary arch

I» Mandibular arch

2. Sex

I» Male

3. Angulations of the Third Molar

~ Vertical

~ Horizontal

~ Distoangular

>- Mesioangular~ Other

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I I

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4. Associated pathology

> Caries)0- Cysts

> Pericoronitis

> Tumours

) Other

) No pathology

5. Age distribution

) Below 15 yrs

> 15 - 19 yrs

> 20- 24 yrs

> 25- 29 yrs

> Over 30

6. Nature of pain

> Continuous

> Sharp

> Dull

> Intermittent

> Other

2