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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.
2
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
3
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.
4
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).
6
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
7
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.
8
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
9
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
10
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.
11
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.
12
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/=
13
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.
~---
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
16
I I
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