Quality of life after extraction of mandibular wisdom teeth: A systematic review

Objective The objective of this systematic review was to evaluate the impact of mandibular wisdom tooth extraction on a patient's quality of life “QoL”. Methods An electronic search was conducted through September 2021 on MEDLINE database, ELSEVIER- ScienceDirect, Ebsco, Scopus and Google Scholar to collect sufficient articles relevant to our subject. Data were extracted and analyzed from selected studies including study type, sample size and characteristics, duration of the observation after removal wisdom teeth, the questionnaire used for evaluation of this QoL and, the result. Results Of 107 studies, fourteen representing 4990 cases met the inclusion criteria. The quality of life has deteriorated but different factors contributed to his improvement. Thus, different instruments have been used in these studies: 24 the OHIP-14, 10 the OHQoLUK, 8 the HRQOL, 2 the EQ-5D-3L QOL, and 1 used UW-QOL. Conclusion The extraction of mandibular wisdom teeth has a negative effect on the quality of life during the first postoperative days but improved progressively by following the medical instructions given by the dental surgeon.


Introduction
The extraction of mandibular wisdom teeth represents the most frequent surgical procedure performed in oral surgery with a percentage of 5 million per year in the United States [1][2][3][4]8,14,16]. Different complications are frequently encountered in the majority of the population in the first few days following this extraction such as: osteitis, alveolitis, pain, trismus, edema as well as a difficulty of swallowing [2,3,10,16]. Thus, it should be noted that these complications might significantly lead to deterioration in the quality of life (QoL) during the immediate postoperative period [1,8,9] (Tables 5 and 6).
Quality of life can be defined as "a state of well-being" which is based on two components. The first is the ability to perform daily activities that reflect physical, psychological, and social well-being and the second is the patient's satisfaction with the level of functioning, control of disease, and treatment-related symptoms [15,16].
For the assessment of this quality of life, several instruments have been used. We can identify in the study of Shugars et al. [3] the HRQOL, which allows us to appreciate the perception after the surgical extraction of mandibular wisdom tooth according to 4 domains "oral function, general activity, signs and symptoms, pain". In addition, Matijevic et al. [7] and Braimah et al. [11] used OHIP-14 or OHQoL-UK [11] to evaluate the quality of life with positive and negative aspects after this surgery.
This systematic review of the literature aimed to determine the impact of the surgical removal of the third molar on physical, psychological, and social well-being by using different instruments. In addition, to expose the different measures, which contribute to his improvement.

Materials and methods
We conducted this review according to the Cochrane Handbook of Systematic Reviews and Interventions, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines [12,13]. It was registered on PROSPERO (ID: CRD42022319556).

Criteria for considering studies for this review
Types of studies: prospective and retrospective studies, observational and randomized clinical trials.
Types of participants: Patients in good health who underwent surgical extraction of mandibular wisdom teeth.
Types of interventions: Extraction of the mandibular wisdom tooth in different positions: "horizontal, vertical and mesio or disto-position". Types of outcome measures: The main objective was to determine the severity of quality of life impairment after mandibular wisdom teeth extraction by using different types of questionnaires.
The primary outcome: depending on the postoperative days, this QoL differs with a significant deterioration in the 1st days but gradually improves.
The secondary result: Several procedures have been reported in the literature to improve the quality of life of patients after mandibular wisdom teeth extraction.

Selection of studies
To identify studies included in or considered for this review, we developed detailed search strategies for each database searched until September 2021. Based on the search strategy developed for MEDLINE but revised appropriately for each database. A PICO approach was used in the databases search with MeSH and text words.
The electronic data resources used were "National Library of Medicine, Washington" (MEDLINE-PubMed); the Cochrane Central Register of Controlled Trials (CENTRAL); (CINAHL-EBSCOhost); (ELSEVIER-ScienceDirect), (SCOPUS). The search was limited to human clinical studies and the last electronic search was performed in September 2021. The reference lists of the articles identified were cross-checked for other relevant articles (Table 1).

Data collection and analysis
Two review authors (LH and BC) separately examined the title and abstract of each article identified by the different search strategies. The authors classified relevant studies.

Inclusion and exclusion criteria
Publications written in English and French were included. While those in Arabic language systemic reviews, studies that did not include questionnaires, and those focusing on upper wisdom teeth were excluded.

Data extraction and management
All studies responding to the inclusion criteria underwent data extraction performed by at least two review authors. Both reviewers used a standardized data extraction sheet with the following parameters: study type, questionnaire quality of life, treatment in the control or placebo group, the total number of patients, and the total duration of observation.
We present the characteristics of trial participants, interventions, and outcomes for the trials in the Characteristics of included studies.

Study selection
A total of 107 studies were identified. Of this, 13 duplicate articles were excluded, which resulted in 94 articles for analysis. After selected titles and abstracts according to the eligibility criteria required for our study, 74 full-text articles remained, of which 20 were excluded at this stage. Finally, 40 articles comprising 4990 patients were selected for inclusion in our work ( Table 2).

Study results
For the evaluation of the quality of life after removal of mandibular  Table 2 Flow diagram showing the process of inclusion of the studies. The administration of an iodine-containing tampon in the socket after the extraction of impacted mandibular third molars has a positive impact on the oral health related quality of life.

Average age 25.1 years
Beech AN et al [24] 2018 Observational study Clinics 30 patients 1-7 days EQ-5D-3L QOL The use of a home facial cooling system "The Hilotherm" provides an improvement in the quality of life after extraction of the impacted mandibular wisdom tooth.

Aged between 18 and 25 years
Ibikunle AA et al [25] 2017 Observational study Clinics 124 patients aged between 18 and 51 years The patients' quality of life was impaired on days 1 and 3 after extraction of the impacted mandibular wisdom tooth, but was significantly improved on day 7 postoperatively. Essen A et al [26] 2017 Retrospective study based on a graph  Ozone therapy showed a significant improvement in quality of life and a reduction in pain after extraction of the impacted mandibular wisdom tooth. Moreover, this treatment had no effect on postoperative swelling and trismus.

Randomized clinical trial
Clinics 60 patients 1-7 days OHIP-14 Intra-and extra-oral low power laser (LLLT) allows good healing, a significant reduction of pain, trismus, and swelling and improved quality of life on days 2 and 7 after extraction of the impacted mandibular wisdom tooth.

Aged between 18 and 30ans
Sancho-Puchades M et al [39] 2012 Prospective study Clinics 50 patients 1-7 days HRQOL-sp The extraction of the impacted mandibular wisdom tooth affects the quality of life especially in the first 5 days. Intraoperative conscious sedation with Midazolam provides comfort for the patient but has no effect in the postoperative period.

Aged between 18 and 25ans
Negreiros RM et al [40]  Concerning the different prescriptions, five studies were interested in the prescription of corticosteroids alone [18,22,30] or associated with NSAIDs [5,6], and three included the effect of antibiotic therapy or prophylaxis [26,28,47].
Regarding the general and local factors, seven studies have evaluated the effect of age and sex variation [42](45) [46], smoking, poor oral hygiene [43], the position of the symptomatic or asymptomatic wisdom tooth [21] Features of every single study are reported in Table 3 3

Discussion
The extraction of the impacted mandibular wisdom tooth creates an alteration in the quality of life in the patients postoperatively. This notion of quality of life includes several distinct parameters that describe more precisely the perception of the patient in front of this extraction while taking into account their worries, expectations, and several factors that improve or deteriorate their postoperative period. In relation to the functional limitation: Deepti C et al. [1], Aravena P et al. [2] as well as Shugars DA et al. [3], have represented this after the extraction of the mandibular wisdom teeth by several components. These include difficulty in working, performing sports and leisure activities, discomfort in opening the mouth, which may worsen with the installation of trismus, and difficulties in pronouncing words.
Regarding pain, several authors in particular Xie L et al. [5], Braimah RO et al. [6], Lindeboom JA et al. [19], and Ai Lyn Lau A et al. [22] have discussed the value of preoperative prescription of anti-inflammatory drugs or the use of an iodine tampon in the postoperative socket for pain reduction. We also distinguish the physical disorder represented by a change in diet, the psychological suffering that leads to a temporary depression, but which will decrease until it disappears from the 3rd postoperative day according to most authors [1,3,11]. Now, to assess the impact of mandibular third molar extraction on patient quality of life, the studies in this work have used specific instruments such as OHIP-14, HQoLUK, HRQOL, EQ-5D-3L QOL, and UW-QOL. There was a significant deterioration in quality of life during the first 5 days after extraction of the impacted mandibular wisdom tooth, which improved after the 6th day. The use of these two questionnaires in this study identified that there is no difference between them.

OHQoLUK-16
Chuang SKEt al [45] 2007 Prospective cohort study Regarding the scoring systems, the higher scores of OHIP-14, and HRQOL was correlated with a negative impact on quality of life, especially from day 1 to day 7 postoperatively.
This finding could be explained by the difficulty of the operation involving osteotomy, separation, and incision as well as possible complications such as trismus, edema, and pain associated with surgical removal of the mandibular third molar [25,31,48].
Currently, when the impact of this extraction on quality of life was analyzed separately for each domain, the domain "physical pain" was mostly recorded by patients (91%) [1,6,22,43].
The present results reveal that pain seems to be the main reason for the deterioration of quality of life after this extraction, mainly on the 1st postoperative day [11,48], and decreasing linearly during the follow-up. These results may provide a source of information for clinical planning when considering prescribing analgesics for faster patient recovery.
Many therapies have been proposed by several authors whose goal is to control postoperative pain and ensure a better quality of life such as: "aPDT laser [35], also the low-powered one (LLLT) [39]", ozone therapy [37] and/or hilotherapy [25]. Medication in the form of "intravenous injection of prednisolone [18] and submucosal dexamethasone [5] or even Bromelain [36] etc.

Conclusion
In summary, many studies have been conducted on the extraction of impacted mandibular wisdom teeth, and more specifically those evaluating the clinical quality of life after this extraction. Thus, the difference between these studies, notably the sample size, the protocols of realization, the duration of the study, and the criteria of judgment, allows a more precise exploration of this quality of life in all these parameters.
In the present work, a synthetic conclusion can be formulated: the extraction of impacted mandibular wisdom teeth has a negative effect on the quality of life during the first postoperative days but improves progressively by following good postoperative instructions.

Provenance and peer review
Not commissioned, externally peer-reviewed.

Compliance with ethical standards
This research involved human participants. This was a retrospective analysis of published cases and did not require informed consent. Ethics approval and consent to participate were not included in this review.
2 Was the study population clearly specified and defined?
3 Was the participation rate of eligible persons at least 50%?
Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
5 Was a sample size justification, power description, or variance and effect estimates Provided?
For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?
For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e. g., categories of exposure, or exposure measured as continuous variable)?
Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
10 Was the exposure(s) assessed more than once over time?
Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
Were the outcome assessors blinded to the exposure status of participants?
13 Was loss to follow-up after baseline 20% or less?
Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure (s) and outcome(s)?