International Dental Journal 2015; 65: 169177

SCIENTIFIC RESEARCH REPORT

doi: 10.1111/idj.12165

Decision making in third molar surgery: a survey of

Brazilian oral and maxillofacial surgeons
Igor Batista Camargo1,2,3, Auremir Rocha Melo1, Andr
e Vajgel Fernandes1, Larry L.
Cunningham Jr4, Jos
e R. Laureano Filho5 and Joseph E. Van Sickels6
1
Department of Oral and Maxillofacial Surgery, College of Dentistry of Pernambuco, University of Pernambuco, Camaragibe, Brazil;
2
Captain-Dentist Brazilian Army, Recife-PE, Brazil; 3Military Hospital Area of Recife, Recife, Brazil; 4Division of Oral and Maxillofacial
Surgery, University of Kentucky, Lexington, KY, USA; 5Oral and Maxillofacial Surgery Dental School at Pernambuco, University of
Pernambuco, Camaragibe, Brazil; 6Department of Oral and Maxillofacial Surgery, University of Kentucky, Lexington, KY, USA.

This study was designed to evaluate the variations in decision making among Brazilian oral and maxillofacial surgeons
(OMFS) and trainees in relation to third molar surgery. A survey on 18 diverse clinical situations related to the assess-
ment and treatment of the third molar surgeries was conducted during the 20th Brazilian National OMFS meeting. Par-
ticipants were divided into three groups according to their level of training. Another variable studied was length of
experience. Correlation between the question answers and the variables was analysed using the chi-square test and the f
test. The mean age of participants was 32.68 years, and their mean length of experience was 5.24 years. There were no
statistical differences between the level of training and number of years of experience and the responses to 15 of the 18
questions on clinical situations. However, differences were found in responses to prophylactic extraction of asymptom-
atic third molars, use of non-steriodal anti-inflammatory drugs (NSAIDs) during the preoperative surgical period and the
use of additional imaging to plan extractions. The group with shorter time of experience (3.8  3.94 years) tended to
recommend extractions of asymptomatic third molars more frequently compared with the more experienced surgeons
(P = 0.041). More experienced surgeons used NSAIDs in the preoperative surgical period, whereas the majority of the
youngest surgeons (4.1  5.96 years of experience) did not (P = 0.0042). The certificated trained and in practice group
tended to treat deep lower third molar impactions based on the findings of a panoramic radiograph, without obtaining
additional imaging [cone beam computed tomography (CBCT)] before treatment (P = 0.0132). Decision making regard-
ing third molar treatment differs according to the level of training and is influenced by the number of years of experi-
ence. Therefore, further continuous education programmes in this area are warranted to make recommendations
regarding third molars consistent with the current literature.

Key words: Third molar, oral surgery, survey, decision making, extraction

The management of partially and fully impacted

INTRODUCTION
The removal of third molars is one the most com-
mon operations in oral surgery. However, contro-
versy exists regarding the best treatment option for a
variety of case scenarios. At the same time, the
impacted mandibular third molar is arguably the
most widely researched subject in oral surgery. In
spite of this enormous interest, there is a lack of
consensus regarding third molar surgery between oral
surgeons1. Most published guidelines are based on a
consensus reached among experts at meetings con-
vened by professional associations, such as the Amer-
ican Association of Oral and Maxillofacial Surgeons
(AAOMS).
2015 FDI World Dental Federation
third molars differs among dental practitioners and in
different schools and different countries. In Sweden,
oral surgeons schedule third molar removal signifi-
cantly more often compared with their colleagues
in the UK2. It is difficult to trace the source of
differences between the two countries. There may be
differences in underlying factors, such as culture
(patient demand), treatment methods (local anaesthe-
sia vs. general anaesthesia), economics, as well as
personal choice. Within the same country there can be
different philosophies of treatment.
In light of the current emphasis on evidence-based
decisions in clinical practice, it is prudent to evaluate
decisions for or against removal of a mandibular third
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Camargo et al.
molar, radiographic assessment of the third molar,
assessment of surgical difficulty, prophylactic use of
antibiotics, control of short-term postoperative mor-
bidity and prevention of lingual nerve injury. All these
factors should be continuously discussed.
The purpose of this study was to analyse the influ-
ence of level of training and the surgeons experience
on third molar surgery decision-making processes by
Brazilian oral and maxillofacial surgeons currently
working in different environments.
MATERIALS AND METHODS
There were 1180 attendees at the 20th Brazilian
National Conference on Oral and Maxillofacial Surgery
(COBRAC): residents; specialists with and without
board certification; and specialists with Masters/Doctor-
ate degrees. Participants were asked to complete a ques-
tionnaire, developed by the University of Pernambuco
post-graduation programme, regarding demographic
and work habits related to third molar surgery. To per-
mit comparison of the effects of different levels of educa-
tion/training, the subjects were divided in three groups,
as follows: Residents; Certificated/Specialists trained and
in practice; and Certificated trained and in practice with
a Masters degree (MSc) and/or a Doctorate degree
(PhD). The second variable studied was length of experi-
ence, which was calculated, in years, from the time of
graduation from dental school. To collect the data, two
postgraduate students in oral and maxillofacial surgery,
who were trained and calibrated for use of the question-
naire, interviewed a random sample of attendees during
the event that received the questionnaire that was
attached to the welcome documentation pack received at
the event. The current study was conducted in full accor-
dance with ethical principles, including the World Medi-
cal Association Declaration of Helsinki, and received
approval from the University of Pernambuco Institu-
tional Ethics Committee (CAAE/UPE 0117.0.097.000-
09). All interviewees signed a statement of informed con-
sent.
The questionnaires were generated to access recom-
mendations regarding: the indications for prophylactic
removal of asymptomatic third molars; the relationship
between third molars and dental crowding; the rela-
tionship between third molars and periodontal defects
on the adjacent teeth; the routine use of antibiotics; the
routine use of corticosteroids; and the routine use of
preoperative non-steroidal anti-inflammatory drugs
(NSAIDs). Additional questions included asymptomatic
impacted third molars with a follicular space up to 2.5
mm wide; use of sedation to perform third molar
removal; and existence of emergency equipment and
medication in their practice. Finally, participants were
asked if the choice of drugs used in third molar surgery
was based on personal experience or recent literature.
170
Different mandibular third molar case scenarios
were presented to the participants. They were asked
to choose which treatment they would recommend in
each case according to the following situation: use of
cone beam computed tomography (CBCT) to evaluate
the relationship between the root and mandibular
canal; and how to manage root tips. Additionally,
they were asked about the classifications used to indi-
cate third molar removal; about the systematic send-
ing of follicles for histopathological analysis; and,
finally, about the type of incision/flap used, suture
used, osteotomy/ostectomy and retraction of the lin-
gual flap. Participants were told to choose only one
answer to each question. Those who chose more than
one or left any blank were excluded. Residents and
oral surgeons were further asked to state when they
graduated from dental school.
Before the study began, a pretest of the question-
naire was performed with the participants of an oral
and maxillofacial surgery continuing education
course at the Pernambuco School of Dentistry, Uni-
versidade de Pernambuco (Brazil). Data were col-
lected and analysed, using the Statistical Package for
the Social Sciences (SPSS) version 16.0 (SPSS Inc,
Chicago, IL, USA), by the Department of Statistics
of the University of Kentucky. Associations between
number of years of experience and level of training
related to the treatment choice were analysed using
the chi-square test. For comparisons between years
of experience and answers, P values were obtained
from two sample t-tests of the difference of means
for the answer groups. An f test was used to analyse
the overall relationship in the variable that had three
categories. A value of P < 0.05 was considered statis-
tically significant.
RESULTS
Of 1180 participants, 94 (7.97%) answered the ques-
tionnaire in a valid way. The participants included
611 specialists in oral and maxillofacial surgery with
different levels of training and 569 residents currently
undergoing training in oral and maxillofacial surgery.
Of our sample of participants, 33 had obtained fur-
ther degrees after training in oral and maxillofacial
surgery: 16 had a Masters degree (MSc) and 17 had
a Doctorate degree (PhD). Thirty-two were Oral and
Maxillofacial Surgery Board Certificated (Brazil Board
of Oral and Maxillofacial Surgery) and 29 were resi-
dents. The average (standard deviation) age of the
participants was 32.68 (7.97) years. The length of
experience was 5.24  6.46 years. The length of time
from graduation ranged from 3 months to 32 years
and 8 months. The residents who participated per-
formed complicated extractions in their daily practice.
This group had a mean of 1.82 years of experience,
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whereas oral and maxillofacial surgeons with an MSc
or a PhD had 7.56 years of experience.
There were no statistical differences between the
variables levels of training and length of experience
related to 15 of the 18 questions (Table 1). However,
differences were found in responses to the prophylac-
tic extraction of asymptomatic third molars, use of
NSAIDs during the preoperative surgical period and
the use of additional imaging (CBCT) to plan extrac-
tions.
Table 2 summarises participants recommendations
for various conditions of third molars. There were no
statistical differences between the variables level of
training and number of years of experience and the
responses given to eight of the 10 questions presented
in this table. However, differences were found in
responses to the recommendation of prophylactic
extraction of asymptomatic third molars (P = 0.041),
in which the group with shorter time of experience
(mean  standard deviation: 3.8  3.94 years) recom-
mended this practice more frequently than did the
Table 1 Third molar treatment decisions made/rec-
ommendations questionnaire
Do you usually perform prophylactic removal of asymptomatic
third molars?
Do you believe that the lower third molar is responsible for dental
crowding?
Do you believe that the presence of a partially erupted third molar
increases the risk of developing periodontal disease in the adjacent
teeth?
Panoramic X-ray shows a radiolucency of up to 2.5 mm at its
greatest diameter surrounding the crown of a completely impacted
asymptomatic third molar. How do you proceed?
Do you usually use sedation for anxious patients during third molar
surgery?
In your private office do you have the equipment necessary for
initial care in cases of emergencies?
Do you routinely prescribe corticosteroids during third molar
surgery?
Do you use NSAIDs as premedication to control pain, swelling and
trismus in third molar surgery?
Do you routinely use antibiotic prophylaxis (excluding endocarditis)
in the extractions of asymptomatic third molars?
Your choice of medications in impacted third molars surgeries is
based on?
Third molars indicated for extraction have a direct relationship
between the roots and the mandibular canal in the panoramic
X-ray. How would you proceed?
During removal of a third molar the root apex fractures, retaining
at least 2 mm of the root. How do you proceed?
To determine the need for removal of an asymptomatic third molar
do you use the classification of Pell & Gregory and Winter?
In clinical practice, do you routinely send the follicular tissue for
histopathological examination, regardless of its size?
What type of incision/flap do you usually use when performing the
third molar surgery?
When you perform the anterior/posterior releasing incision, how do
you suture?
What type of system/instrument do you use for extractions of
impacted third molar (regardless of upper or lower)?
Do you usually detach and retract the lingual flap for removal of an
impacted lower third molar?
NSAID, non-steriodal anti-inflammatory drug.
2015 FDI World Dental Federation
Brazilian OMFS third molar survey
more experienced surgeons (mean  standard devia-
tion: 8.7693  9.56 years), and to the use of NSAIDs
in the preoperative surgical period the majority of
surgeons with shorter time of experience (mean 
standard deviation: 4.1  5.96 years) tended to not
use this practice (P = 0.0042).
Table 3 presents the distribution of decision making
according to the surgical technique used by surgeons
during the extraction. Again, there were no statistical
differences between the variables studied in the
responses to seven of the eight questions presented in
the table. Here, the exception occurred in the group
of specialist/board certified surgeons. They tended to
treat deep lower third molar impactions based only
on the findings of a panoramic radiograph without
obtaining additional imaging (CBCT). This same
group used coronectomy as a treatment plan twice as
frequently as residents and those in the MSc/PhD
degree group, to access deep lower third molars in
which the root was associated with the inferior alveo-
lar nerve (P = 0.0132).
DISCUSSION
Third molar removal is one of the most frequently
performed operations in oral and maxillofacial sur-
gery. The issues studied here were obtained from pub-
lished data that reported differences between junior
surgeons and a group of surgeons in planning treat-
ment of third molars. Because of the relative lack of
experience of residents, they might interpret the situa-
tion differently, and make different recommendations,
compared with senior surgeons. It was expected that
those with less experience would underestimate surgi-
cal difficulty3. Differences in treatment planning are
not only related to the surgeons experience but can
also be the result of cultural influences, as seen in dif-
ferent countries and even in the same country1. The
attendees at the 20th Brazilian Oral and Maxillofacial
Surgery Meeting were very heterogeneous and com-
prised surgeons from all the states of the Brazilian
confederation. Our questionnaire did not evaluate the
aspect of institution of training; therefore, we could
not correlate this to our results.
A recent publication concluded that the preopera-
tive prediction of the surgical difficulty of mandibular
third molar tooth removal is unreliable, not only for
residents, but also for senior surgeons4. An example
of this is that the majority of responses to questions
in our survey did not show statistical differences
between the groups when the length of experience
and level of training was considered for the treatment
planning of third molar surgery. This pattern of divi-
sion of opinions can be observed in our findings seen
in both tables. Choice of medications, use of sedation
and use of antibiotics was almost evenly split between
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Camargo et al.

Table 2 Correlation of third molar treatment recommendations to the level of training and length of experience
Recommendations Level of training Length of Recommendations Level of training Length of
experience experience
(years) (years)

Prophylactic removal of General practitioner/ Yes 72.41% 1.82 Have equipment for General practitioner/ Yes 68.96% 1.82
third molars Resident No 27.59% emergency care in the Resident No 31.04%
Specialist/Board Yes 65.62% 5.93 private dental office Specialist/Board Yes 87.05% 5.93
certificated No 34.38% certificated No 12.05%
Masters degree/PhD Yes 75.75% 7.56 Masters degree/PhD Yes 87.88% 7.56
No 24.24% No 12.12%
Believes that lower General practitioner/ Yes 27.59% 1.82 Use corticoid General practitioner/ Yes 58.62% 1.82
third molar causes Resident No 72.41% prophylaxis (as Resident No 41.38%
dental crowding Specialist/Board Yes 34.38% 5.93 pre- and postoperative Specialist/Board Yes 65.63% 5.93
certificated No 65.62% medication for pain, certificated No 34.37%
Masters degree/PhD Yes 36.36% 7.56 oedema and trismus Masters degree/PhD Yes 69.70% 7.56
No 63.64% control) No 30.30%
Believes that third General practitioner/ Yes 82.76% 1.82 Use of NSAIDs (as General practitioner/ Yes 13.80% 1.82
molars can cause Resident No 17.24% preoperative Resident No 86.20%
periodontal defects in Specialist/Board Yes 81.25% 5.93 medication for pain, Specialist/Board Yes 34.37% 5.93
adjacent tooth certificated No 18.75% oedema and trismus certificated No 65.63%
Masters degree/PhD Yes 75.76% 7.56 control) Masters degree/PhD Yes 30.31% 7.56
No 24.24% No 69.69%
Removal versus follow General practitioner/ Remove 75.86% 1.82 Use of antibiotic General practitioner/ Yes 72.41% 1.82
up of asymptomatic Resident Follow up 24.14% prophylaxis (excluding Resident No 27.59%
third molars with Specialist/Board Remove 84.38% 5.93 endocarditis) Specialist/Board Yes 65.62% 5.93
2.5-mm-wide follicle certificated Follow up 15.62% certificated No 34.38%
on panoramic Masters degree/PhD Remove 75.76% 7.56 Master degree/ Yes 75.76% 7.56
radiographs Follow up 24.24% PhD degree No 24.24%
Use of sedation for General practitioner/ Yes 44.82% 1.82 Choice of medications General practitioner/ Individual 44.83% 1.82
third-molar removal Resident to be used in third Resident experience
No 55.18% molar surgery is based Scientific data 55.17%
Specialist/Board Yes 53.13% 5.93 on: Specialist/Board Individual 50% 5.93
certificated certificated experience
No 46.87% Scientific data 50%
Masters degree/PhD Yes 51.52% 7.56 Masters degree/PhD Individual 27.27% 7.56
experience
No 48.48% Scientific data 72.73%

NSAIDs, non-steroidal anti-inflammatory drugs.

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 Table 3 Correlation of third molar treatment decisions made to the level of training and length of experience
Decisions made Level of training Length of Decisions Level of training Length of
experience made experience
(years) (years)

2015 FDI World Dental Federation

Use of CBCT to General practitioner/ CBCT 65.51% 1.82 Type of General practitioner/ Envelope 41.38% 1.82
evaluate close Resident Panoramic 31.04% incision/flap Resident
relationship between Perform 3.45% With anterior 58.62%
root apex and coronectomy releasing incision
mandibular canal w/o CBCT
Specialist/Board CBCT 37.5% 5.93 Specialist/Board Envelope 40.63% 5.93
certificated Panoramic 53.13% certificated
Perform 9.37% With anterior 59.37%
coronectomy releasing incision
w/o CBCT
Masters degree/PhD CBCT 75.76% 7.56 Masters degree/PhD Envelope 39.39% 7.56
Panoramic 21.21%
Perform 3.03% With anterior 60.61%
coronectomy releasing incision
w/o CBCT
Transoperative root General practitioner/ Remove 31.03% 1.82 Type of General practitioner/ Hermetic/tight 68.97% 1.82
apex (<2 mm) Resident Leave 68.97% flap suture Resident W/spaces for 31.03%
fractured during drainage
extraction Specialist/Board Remove 28.13% 5.93 Specialist/Board Hermetic/tight 75% 5.93
certificated Leave 71.87% certificated W/spaces for 25%
drainage
Masters degree/PhD Remove 33.33% 7.56 Masters degree/PhD Hermetic/tight 72.73% 7.56
Leave 66.67% W/spaces for 27.27%
drainage
Use classification of Pell General practitioner/ Yes 48.28% 1.82 Type of General practitioner/ Turbines 96.55% 1.82
& Gregory/Winter to Resident No 51.72% osteotomy/ Resident Low/medium speed 3.45%
indicate asymptomatic Specialist/Board Yes 50% 5.93 ostectomy Specialist/Board Turbines 90.63% 5.93
removals certificated No 50% certificated Low/medium speed 9.37%
Masters degree/PhD Yes 48.48% 7.56 Masters degree/PhD Turbines 75.75% 7.56
No 51.52% Low/medium speed 24.25%
Systematic sending of General practitioner/ Yes 6.90% 1.82 Release of General practitioner/ Yes 20.69% 1.82
follicles, regardless of Resident No 93.10% lingual flap Resident No 79.31%
size, for Specialist/Board Yes 9.38% 5.93 in lower Specialist/Board Yes 15.63% 5.93
histopathology certificated No 90.62% thirds certificated No 84.37%
assessment Masters degree/PhD Yes 24.24% 7.56 Masters degree/PhD Yes 18.18% 7.56
No 75.74% No 81.82%

CBCT, cone beam computed tomography; W, with; w/o, without.

Brazilian OMFS third molar survey

173
Camargo et al.
the groups. In relation to antibiotic use, a pattern
similar to that in the present study has also been
described by the AAOMS, who reported that such
therapy may or may not help5. Regarding the use of
sedation, despite the fact that one recent study con-
cluded that impacted lower third molar extractions
are significantly more difficult in anxious patients6,
Brazilian surgeons did not demonstrate a general
tendency to follow this practice. This same pattern of
divided opinion occurred with: type of incision; oste-
otomy; flap and suture used; the scientifically based
choice of medications; removal or follow up of a
tooth with radiographic signs of pathology; as well as
systematic referral of follicles for pathology analysis.
All of those recommendations/decisions made were
different among the groups of surgeons, based on
reports of their day-to-day practices (Tables 2 and 3).
The other variables studied (i.e. questions), for which
we found significant differences, are discussed in the
next section.
Prophylactic removal of the third molar
Management of asymptomatic partially and fully
impacted mandibular third molars differs among
dental practitioners7. Survey studies performed in
Oral Surgery Clinics in Sweden found that the indica-
tion for removal was classified as prophylactic in
27% and orthodontic in 14%8 in which there is great
variation among oral surgeons in their judgment on
the need for removal of asymptomatic mandibular
third molars9, where the only factor that influenced
the indication for removal of molars with no disease
was the patients age.10
Our results showed that the level of experience
influences the decision-making process. We found that
surgeons with more than 8 years of experience prefer
to follow up, rather than extract, asymptomatic third
molars. There was agreement with the results of
Zadick and Levin1, that young Israeli dentists recom-
mended removal of third molars significantly more
often than did Eastern European and South American
dentists. In our findings, the group of Brazilian oral
surgeons with fewer years of experience recommended
removal of third molars significantly more often com-
pared with more experienced surgeons.
Consensus states that extraction of symptomatic
and/or diseased mandibular third molars is appropri-
ate treatment9,11. However, prophylactic removal of
asymptomatic disease-free mandibular third molars is
controversial among practitioners, in spite of the clear
contraindication for the operation reported in recent
literature and by AOOMS, AHA, AMA, ADA for
patients with systemic diseases unresponsive to
medication9,1214. Almendros-Marques et al.15 used a
questionnaire addressing the decision to perform, and
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the degree of confidence in the indication for, prophy-
lactic removal related to 40 asymptomatic impacted
lower third molars. The questionnaire was presented
to four professionals with different levels of surgical
experience. Each professional received information
relating to the patients (age and sex, molar inclination
and degree of impaction, and the absence of symp-
tomatology). Their results showed no statistically sig-
nificant differences between residents and trainers in
terms of the decision to remove. The management
approach adopted by oral surgeons regarding the
removal of asymptomatic impacted lower third molars
depends upon the perceived risk of complications if
such teeth are not removed. Therefore, Almendros-
Marques et al. found that the surgical experience does
not seem to influence treatment decision, a finding in
contrast to that of the present study.
Another finding is that we included Brazilian sur-
geons who finished their training at different centres in
Brazil and abroad. One study, with a similar method-
ology of survey regarding the management of unerupt-
ed mandibular asymptomatic impacted wisdom teeth,
reported a significant difference in approach between
oral and maxillofacial surgeons in Hong Kong and
Glasgow, with the former showing a greater tendency
towards extraction of asymptomatic teeth16.
Third molar/periodontal disease and dental crowding
More than 75% of the surgeons who participated in
our survey believe that the third molar can cause peri-
odontal defects of the distal aspect of the second
molar or the adjacent tooth, and more than 63% do
not believe that the third molar can cause dental
crowding.
In 2014, a group from Lithuania17 published a sys-
tematic literature review on the correlation of third
molars to the occurrence of lower anterior dental
crowding. The authors reviewed 223 articles, pub-
lished from 1971 to 2011, and selected 21 papers.
Their results are similar to ours in that they are rather
contradictory: some authors/meetings support the
opinion that mandibular third molars cause teeth
crowding, whereas others do not. Another survey18
compared the opinion of oral surgeons and orthodon-
tists on this issue. They found that surgeons were
more likely to generally or sometimes recommend
prophylactic removal of mandibular third molars to
prevent crowding, whereas orthodontists more often
said that they rarely or never recommend it. In con-
trast to our results, which did not find a correlation
between number of years of experience and this issue,
those authors found that the differences in orthodon-
tists and oral and maxillofacial surgeons beliefs were
significantly related to the number of years since gra-
duation. Orthodontists who had graduated more
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recently were less likely to recommend prophylactic
removal of third molars to prevent crowding, and sur-
geons were more likely to recommend removal if they
graduated in the 1970s or 1980s.
In an editorial, Assael19 advocated the elective
removal of all third molars in young adults to miti-
gate the risks of systemic inflammation and the local
progression of emergent periodontal disease. There
are data showing that the periodontal status of second
molars tends to improve after extraction of third
molars that exhibit periodontal pathology20. There-
fore, the association between periodontitis and asymp-
tomatic third molars was studied in a trial that
included 329 patients, and the results showed that a
higher proportion of patients 25 years of age had
pocket depths of 5 mm on the distal surface of sec-
ond molars or around third molars compared with
patients under 25 years of age (33% vs. 17%, respec-
tively). The distal surfaces of second molars and third
molars in the mandible were affected more than those
in the maxilla (25% vs. 5%, respectively)5. Related
to the issue of periodontal problems caused by the
third molars, the majority of the responses in our
study agreed that these consequences can occur; there
were no statistical differences between the study
groups.
Classication of third molars
There are several classifications regarding impacted
third molars according to the Pell and Gregory scales
of position for the occlusal plane (scales AC) and
the ascending ramus of the mandible (scales 13)21.
These scales were eventually regarded as having little
value for predicting the degree of extraction diffi-
culty22, mainly because these systems of classification
introduce error of interpretation by the observer23.
However, they are nowadays used to compare the
prediction of surgical difficulty between groups with
different levels of training and experience4 as well as
to perform demographic population prevalence stud-
ies of pattern of tooth impaction24. The Third Molar
Classification (TMC)25 has a guideline for the surgical
management of impacted third molars, especially in
high-risk cases, where often the surgeon is forced to
rely mainly on experience and clinical judgment25.
Our results showed a division in our study groups
regarding use of the TMC, in that almost half use the
classification for the management and planning of
third molar extraction and the other half did not use
any type of rating. As a result of the difficulty men-
tioned above related to the lack of a universal, reli-
able, reproducible and easy-to-use method to classify
routine third molar cases on a surgical basis, further
studies with new third molar classification systems is
warranted.
2015 FDI World Dental Federation
Brazilian OMFS third molar survey
CBCT evaluation of relationship between third molar
and mandibular nerve
Because of large variation in inferior alveolar nerve/
third molar relationships, a detailed preoperative
radiographic assessment is required to identify both the
position (buccal, lingual or inferior) and approxima-
tion of the mandibular canal (MC) to the third molar
to minimise the risk of postoperative dysaesthesia26,27.
Our results showed that oral surgeons with more
years of experience than residents, but fewer than
those with postgraduate qualifications, tended to treat
deep lower third molar impactions based only on the
findings of panoramic radiographs, and would use
coronectomy twice as frequently to access deep lower
third molars in which there was a close relationship
between the root and the inferior alveolar nerve, with-
out resorting to CBCT.
The guidelines published by the European Atomic
Energy Community in 2009 state that CBCT is justi-
fied when conventional radiographs suggest a close
relationship between a mandibular third molar and
the inferior dental canal and when a decision to per-
form surgical removal has been made28. The authors
evaluated the risk assessment for MC injury based on
panoramic radiography compared with CBCT imag-
ing and concluded that it differed significantly. After
review of CBCT images by oral surgeons, significantly
more patients were reclassified as having lower risk
for MC injury compared with assessments from pano-
ramic radiographs, and they showed that CBCT imag-
ing contributes to more comprehensive surgical
planning and risk assessment, which may minimise
the risk of MC injury29.
Previous studies have assumed that most clinicians
use panoramic radiographs with a series of radiologi-
cal criteria as an indicator of the relationship, and
thus the risk, of postoperative dysaesthesia27. In a
Web-based survey of 2,713 Italian dentists (11.9% of
answers) concluded that recommendations for CT
were proportional to the number of radiographic signs
indicating a risk of inferior alveolar nerve injury28.
Our results agree with the findings that the majority
of Australian oral and maxillofacial surgeons rely
upon the results of a panoramic radiograph for the
diagnosis of the proximity of lower third molars to
the MC, even though many did not consider this
image to be the ideal diagnostic tool29.
Use of preoperative NSAIDs in third molar surgery
The acute postoperative pain following surgical
extraction of an impacted third molar has been shown
to be primarily inflammatory. Accordingly, the use of
NSAIDs in this context is appropriate and can be
effective. Several types of NSAIDs are used, but
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Camargo et al.
almost no information exists on why preference is
given to one rather than another. Our findings
showed a strong correlation in that the majority of
Brazilian oral surgeons follow this recommendation
but a consistent number of young surgeons with fewer
than 5 years of experience, similarly to Oral surgeons
in USA, do not routinely use NSAIDs preoperatively.
An Italian observational, multicenter, prospective
survey study30 evaluated the pattern of administration
of NSAIDs in patients undergoing surgery for extrac-
tion of an impacted third molar. The study also aimed
to collect information on the efficacy, onset and dura-
tion of the analgesic effect of routinely prescribed
NSAIDs and to assess the duration of treatment with
these drugs and their tolerability. In their study group
of 616 patients, they found that nimesulide was the
most commonly prescribed NSAID (68%), followed
by diclofenac, ketoprofen and ibuprofen. The results
of this study also showed that nimesulide, especially
when given before patients started experiencing pain
after surgery, was more effective than the other NSA-
IDs in reducing the severity of pain on the day of sur-
gery, in delaying the time to maximum intensity of
pain, in providing complete pain relief and in prolong-
ing the duration of the analgesic effect on the day of
surgery.
In this same line of thinking, it has been well docu-
mented that systemic corticosteroids result in less
swelling and a more positive experience without
added risk5. However, our results showed that the
adoption of this practice is not homogenous between
the groups and is not a consensus between the sub-
jects of the same group.
CONCLUSIONS
Even though only 94 of the 1180 meeting attendees
answered the questionnaire in a valid manner, the
results of the current study reveal that most oral and
maxillofacial surgeons behave differently regarding
the way they treat third molars clinically. Most treat
patients in accordance with the current literature. The
number of years of experience and level of training
seems to influence the frequency according to which
the surgeon decides to use a CBCT to perform an
impacted molar procedure, as well as being related to
the indications for extraction of asymptomatic third
molars.
Acknowledgements
To CAPES/CNPq and Brazilian Army for the Scholar-
ship and Permission to the first author to perform the
Research Fellow in the University of Kentucky. Mr
David A. Akers from Department of Statistics of Uni-
versity of Kentucky for the statistical analyses. We
176
state that all the authors have viewed and agreed to
the submission.
Conict of Interest
No conflict of interest.
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Correspondence to:
Igor B. Camargo,

Hospital Militar de Area do Recife,
Rua General Salgado,
95 Apto 103,
Recife 51130-320, Brazil.
And
1435 Nicholasville Road Apto 1020,
Lexington, KY 40503, USA.
Emails: igorbcamargo@gmail.com or
igor.camargo@uky.edu
177
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