RESEARCHoral surgery in predicting future pathology. 12,13 The most frequently cited criteria for the removal of lower third molars are those developed at the 1979 conference of the American National Institutes of Health (NIH). 8 Decision analyses of the risks and benefits of prophylactic removal have concluded that prophylactic surgical extraction is not in patients' best interests. 13 Nerve damage resulting in lingual and/or labial paraesthesia or anaesthesia is perceived as particularly debilitating by patients. 14 From such studies the surgical outcomes considered to reduce health to the greatest degree included nerve damage causing permanent anaesthesia of the lip, tongue, or both lip and tongue. Decision analyses have also shown that prophylactic lower third molar removal is unwarranted both on the basis of patient derived utilities and those derived from oral surgeons. 15 A great deal of research has been undertaken in relation to the incidence of nerve injury during lower third molar surgery, but little is known about the factors affecting the rate of damage. Surgical technique is one area that has been examined in this context. A randomised comparison of the lingual split procedure and removal using surgical burs did not find significant differences 16 though there is now strong evidence that lingual nerve damage is substantially less likely if a lingual flap is not raised. 17 A number of studies point to the elevation of the lingual flap as the most important surgical factor causing lingual nerve damage. 2,18 The study reported here was designed to investigate the importance of factors (pathology, eruption status, age and anaesthetic modality) that might influence the rate of nerve damage during third molar surgery. MethodsData were collected in relation to all patients selected for surgery from a series of 500 consecutive patients referred to consultant oral and maxillofacial surgeons for lower third molar assessment. These patients were recruited over an 11-month period. Patients were unselected on the basis of age, gender, or social class. 19 All patients seeking an opinion regarding their third molars were included though cases where this was not the primary focus of referral were excluded. For example a patient attended with a fractured lower jaw and, inter alia, was considered for removal of third molars.Patients were examined by one of four consultants or their designated deputies and treatment was planned in the standard manner. Immediately following this consultation the patients were examined and interviewed by a research hygienist in the same clinical area (though not in the presence of other clinical staff). This worker was appointed specifically to undertake this project and had wide experience of clinical assessment. The hygienist collected data on a standard proforma and recorded demographic information, clinical history and medical history. Maximum mouth opening, extra oral swelling, degree of eruption of each lower third molar, evidence of current pericoronitis, presence and site of ca...
Objective To assess patient preferences regarding the treatment of menorrhagia using the multiattribute utility methodologies, to produce a clinically applicable scale, and to assess health outcomes following treatment of menorrhagia. Methods Women referred to the gynaecology department for the treatment of menorrhagia were interviewed regarding the effects of menorrhagia on different aspects of their life. Their concerns were categorised into main components of health (domains). The relative importance of each domain was rated by the women using importance points which were distributed to represent the perceived importance of each domain. A series of statements (intra-domain statements) was developed for each domain, which described various possible conditions of that component of health. These were also rated using a one metre visual analogue scale with numerical anchor points at zero (worst) and 100 (best). Results The components of health considered most important were, in order of impact, family life, followed by physical health, work life, psychological health, practical difficulties and social life. The scores for the intra-domain statements were combined into a scale to allow the calculation of a final health state utility for a particular outcome based upon the statements the patient chooses within each domain. In planning treatment for menorrhagia clinicians can assess a woman's current perception of their health, using a simple to administer clinical scale.
The objective of the study was to identify those factors that should affect treatment planning for patients who have lower third molars, using decision-analytic techniques. Utility values based on data from 104 patients indicated that the respondents considered that postoperative complications (except mild pain and temporary paresthesia) reduced health to a greater degree than did complications following non-intervention. A decision analysis indicated that the maximum expected utility of prophylactic third-molar surgery (60.25) was lower than that for non-intervention (76.96). The decision was sensitive to changes in the probabilities of occurrence of recurrent pericoronitis (threshold = 0.52), resorption of an adjacent tooth (threshold = 0.29), loss of an adjacent tooth (threshold = 0.32), and cystic change (threshold = 0.34). These thresholds are much higher than the incidence of problems affecting the lower third molar shown by a concurrent clinical audit and literature review. This study therefore suggests that lower third molars should not be removed prophylactically.
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