Vol.:(0123456789)1 3

Quality of Life Research

https://doi.org/10.1007/s11136-018-1889-1

REVIEW

Third molar removal and its impact on quality of life: systematic review and meta-analysis

Lucas Duarte-Rodrigues1 · Ednele Fabyene Primo Miranda1 · Taiane Oliveira Souza1 · Haroldo Neves de Paiva2 ·

Saulo Gabriel Moreira Falci3 · Endi Lanza Galvão4

Accepted: 22 May 2018

© Springer International Publishing AG, part of Springer Nature 2018

Abstract

Objective The purpose of this systematic review was to assess the impact of third molar removal on patient’s quality of life.

Methods To address the study purpose, investigators designed and implemented a systematic review. The primary outcome

variable was the quality of life after third molar extraction. An electronic search was conducted through March, 2017, on

the PUBMED, Virtual Health Library (VHL), Web of Science, and OVID, to identify relevant literatures. Research studies

(randomized or non-randomized clinical trials) were included that evaluated the quality of life in individuals before and after

third molar extraction, using validated measures of oral health-related quality of life with quantitative approach, besides

procedures performed under local anesthesia. The R software was used to measure the mean difference on the quality of life

between the preoperative period and follow-up days.

Results A total of 1141 studies were identified. Of this total, 13 articles were selected in the present systematic review,

of which six studies were included in the meta-analysis. All of these 13 articles used the OHIP-14, and 4 of this 13 used

OHQoLUK-16 to evaluate the quality of life. Regarding quality assessment, four of the 13 included studies in this review

received a maximum score of 9 points, according to the Newcastle–Ottawa (NOS). The OHIP-14 mean score on the first

postoperative day was 17.57 (95% CI 11.84–23.30, I2 = 96%) higher than the preoperative period. On the seventh postopera-

tive day, the quality of life assessed by OHIP-14 got worse again.

Conclusion This systematic review revealed that the highest negative impact on quality of life of individuals submitted to

third molar surgery was observed on the first postoperative day, decreasing over the follow-up period.

Keywords Quality of life · Third molar surgery · Systematic review · Meta-analysis

Introduction

The concept of oral health-related quality of life (OHRQoL)

refers to the impact of the oral health conditions on daily

activities, quality of life, and the well-being of the individual

[1]. Furthermore, a number of authors suggest that an indi-

vidual’s OHRQoL relates to the perception of how differ-

ent groups of factors affect personal well-being, including

functional factors, psychological factors, social factors, and

the experiences of pain and discomfort [2].

Third molar removal is one of the most common sur-

gical procedures in dentistry due to the possible associa-

tion between the presence of the tooth and certain diseases,

such as caries, periodontitis, pericoronitis, and associated

pathologies such as cysts and benign tumors, as a result

of which these teeth need to be extracted with a high fre-

quency. Although considered a relatively common procedure

Saulo Gabriel Moreira Falci

saulofalci@hotmail.com

1 Department of Pediatric Dentistry and Orthodontics,

Universidade Federal dos Vales do Jequitinhonha e Mucuri,

Rua da Glória, 187, Diamantina, MG 39100-000, Brazil

2 Department of General Dentistry, Universidade Federal

dos Vales do Jequitinhonha e Mucuri, Rua da Glória, 187,

Diamantina, MG 39100-000, Brazil

3 Department of Oral and Maxillofacial Surgery, Universidade

Federal dos Vales do Jequitinhonha e Mucuri, Rua da Glória,

187, Diamantina, MG 39100-000, Brazil

4 René Rachou Institute, Fundação Oswaldo Cruz,

Av. Augusto de Lima, 1715 - Barro Preto, Belo Horizonte,

MG 30190-002, Brazil

Quality of Life Research

1 3

[3], third molar removal is an invasive surgery commonly

performed on otherwise healthy, young people who have

seldom had previous experience with surgery of any kind.

Furthermore, expecting pain as a consequence of third

molar surgery is reasonable due to the damage to gum and

jawbones [4], as well as the presence of other postopera-

tive complications such as trismus, swelling [5], sensitiv-

ity, and alveolitis [6]. Depending on the intensity of these

postoperative complications, an individual who has under-

gone the experience of third molar surgery may need to be

prevented from practicing their daily activities. In this way,

an impaired OHRQol might directly influence the patient´s

overall quality of life.

Besides the postoperative complications, preoperative

complications and the number of molars removed might

also interfere with the quality of life of the individual [6,

7]. Thereby, the assessment of the impact of third molar

surgery on daily activities and the overall well-being of

patient is fundamental for making clinical decisions and giv-

ing adequate instructions during the postoperative period.

More specifically, patient-reported outcomes are important

to assess the severity of symptoms and the effectiveness of

therapy, connecting providers to patient-generated health

data and monitoring general health and well-being [8]. To

our knowledge, there is currently no systematic evidence

available regarding the relationship between third molar sur-

gery and quality of life.

Thus, our main objective was to perform a systematic

review of the literature to assess the observed impact on the

quality of life of patients who undergo third molar surgery.

Secondary objectives were to identify the most commonly

used tools to evaluate OHRQoL and the most compromised

domains of quality of life after third molar removal.

Materials and methods

The present systematic review was performed in agreement

with the preferred reporting items for systematic reviews and

meta-analyses (PRISMA) statement [9] and has been regis-

tered in the International Prospective Register of Systematic

Reviews (PROSPERO; CRD42017053701).

The PICO question was developed, as follows: Popula-

tion: subjects with maxillary and/or mandibular third molars;

Intervention: third molar removal (impacted, erupted, or par-

tially erupted); Comparison: baseline versus postoperative

days; Outcomes: assessment of oral health-related quality

of life, using validated questionnaires with a quantitative

approach.

Search strategy

An electronic search was conducted (through March, 2017)

on the PUBMED, Virtual Health Library (VHL), Web of Sci-

ence, and OVID to identify relevant literatures. The search

was performed using a combination of terms (MeSH) and the

keywords: “Third Molar,” “Third Molars,” “Wisdom Tooth,”

“Wisdom Teeth,” “quality of life,” “life qualities,” “health-

related quality of life,” and “life quality.” Similarly, the gray

literature (Google scholar) was also performed.

Two previously trained reviewers, (EFPM and LDR)

screened the papers, independently. Firstly, titles and abstracts

were examined and papers were included in cases where the

authors had evaluated the quality of life of individuals before

and after third molar extraction using validated measures of

OHRQol with a quantitative approach. Subsequently, papers

selected for full-text reading were analyzed by the review-

ers. All articles in which a randomized or non-randomized

approach was used, and which accessed the quality of life

before and after third molar extraction surgery, were included.

There were no distinctions made regarding symptomatic and

asymptomatic, third molar at baseline, maxillary, or mandib-

ular third molar, or classification of third molar position in

choosing the included papers. The exclusion criteria included

case reports, case series, review article, opinion article, and

studies that did not report assessments both pre- and postop-

eratively. Regarding studies that aimed to investigate drug

interventions or other interventions such as surgical technique

or postoperative management such as the use of ice packs,

in addition to the basic intervention of third molar removal,

only the control group or the standard treatment results were

considered for analysis in these cases. Divergent judgments

between reviewers were solved by consensus. There were no

restrictions on the publication language or date of publication.

Data extraction

Two reviewers (TOS and HNP) independently collected the

following data from the included studies: subjects’ demo-

graphic characteristics (age, gender), study design, follow-up

period, publication year, and country of the study. Likewise,

clinical and medical characteristics were also recorded, such

as the type of third molar removed, drug therapy protocol, the

number of operators, operator calibration, and the impact on

quality of life as assessed before and after third molar surgery.

The first or corresponding authors from the selected studies

were contacted in case of missing information.

Risk of bias (quality) assessment

The risk of bias of the randomized studies was evalu-

ated using the following criteria: (1) double-blind; (2)

Quality of Life Research

1 3

concealment of treatment allocation; (3) blinding of out-

come assessment; and (4) intention-to-treat analysis. In this

way, the review authors’ judgements would be categorized as

“Low risk” of bias, “High risk” of bias or “Unclear risk” of

bias, considering the level of detail reported by the authors

regarding what happened in their study. The assessment of

the quality of the included studies was performed using the

Newcastle–Ottawa scale (NOS) for non-randomized studies

[10]. The NOS evaluates the studies based on three criteria:

selection, comparability, and outcome. A maximum possible

score of 9 stars/points was given for each study. For the final

classification of risk of bias, disagreements between review-

ers were settled by consensus.

Statistical analysis

The meta-analysis was performed using the software R, ver-

sion 3.3.1. The packages “meta” and “metafor” were used

to perform the statistical calculations and to generate the

forest plots. The heterogeneity between the results of the

selected studies was assessed using the I2 test. Since het-

erogeneity was present (I2 > 0) in all tests, the random effect

model was used to perform the meta-analysis [11, 12]. The

effect estimates were expressed as the weighted mean dif-

ferences between groups, and were obtained by comparing

the baseline mean values at the end of the study for each

group. A meta-analysis concerning the frequency of impact

of third molar removal on the quality of life according to

each domain was performed when data were available.

Results

Systematic review

A total of 1141 studies were identified. Of this total, 142

duplicate articles were excluded, resulting in 999 papers for

analysis. After screening by titles and abstracts according

to the eligibility criteria by the two independent reviewers,

fifty-eight articles remained for full-text reading, where

forty-five papers were excluded at this stage. Finally, 13 arti-

cles [4, 7, 13–23], comprising 1178 patients, were selected

in the present systematic review, of which six studies were

included in the meta-analysis. The main reasons for exclu-

sion together with other characteristics of the process are

summarized in Fig. 1.

Study characteristics

The articles evaluated the impact of third molar surgery on

the quality of life of subjects. All included studies used vali-

dated assessment tools, of which the majority applied the

14-item Oral Health Impact Profile (OHIP-14) [4, 7, 13–22]

and the United Kingdom Oral Health Related Quality of Life

measure (OHRQoLUK) [13, 14, 16, 17, 23]. Bradshaw et al.

[17], beyond the OHIP-14, used an instrument designed to

measure the effect of third molar management developed by

Shugars et al. [15] and to characterize the pain further, the

Gracely scale was used for the sensory perception of pain

experienced during the week prior to removal of the third

molar [15]. The follow-up periods of the included studies

ranged from 1 to 180 days. None of the studies reported

the calibration of examiners/operators, and only five gave

information on the number of oral surgeons [7, 19, 20, 22,

23] .The only medications recorded during the surgical pro-

cedure were local anesthetics and a topical antibiotic (topical

minocycline, 1 mg) [15]. The medicines prescribed in the

postoperative period included anti-inflammatories (ibupro-

fen, naproxen sodium) [16, 21–23] and antibiotics, such as

clavulin [23], amoxicillin [19–22], and metronidazole [21,

22]. Overlap of data was identified between two studies [19,

20]. Thus, only one [19] was included in the meta-analysis.

The main characteristics of the studies are presented in

Table 1.

Ibikunle et al. [21] evaluated the change in an individ-

ual’s OHRQoL following third molar surgery with either

oral administration or submucosal injection of prednisolone,

while Ibikunle [22] evaluated the effect of ice pack therapy

on OHRQoL after third molar surgery. However, these stud-

ies were not included in this meta-analysis since they did not

provide data related to standard deviations (SD) of the pre-

sented OHRQoL scores. Kazancioglu et al. [19] evaluated

the influence of ozone on perceptions of the quality of life

for 7 days following third molar extraction, and compared

the results to a control group (without any adjuvant therapy).

Only the control group results of this study were used for

the meta-analysis. Bradshaw et al. [17] presented OHIP-14

scores through median values only (IQR-interquartile), and

these results were not included in this meta-analysis.

All eligible subjects in the study of Bradshaw et al. [17]

were advised to remove the third molar because of symptoms

such as pericoronitis, spontaneous pain, localized swelling,

and purulence. Most of authors recorded only asymptomatic

patients [15, 16, 19, 20] in their studies.

Regarding the impact on quality of life  before third

molar extractions, the mean scores measured by OHIP-14

ranged from 2.43 to 23.62 among the studies [4, 13, 14,

16, 18–21]. Applying the OHRQoLUK index, mean scores

ranged from 50.7 to 53.92 for the same period [13, 14, 16].

After seven postoperative days, mean scores for the OHIP-

14 ranged between 2.57 and 34.26 [4, 13, 14, 16], and using

the OHRQoLUK, these values ranged from 38.35 to 53.0

[13, 14, 16]. One study presented OHIP-14 scores through

median values (IQR-interquartile), which ranged from

12.5 (IQR 5.0–18.0) at enrollment to 1.0 (IQR 0–3.0) after

third molar surgery [17]. Furthermore, McGrath et al. [14]

Quality of Life Research

1 3

assessed the impact of third molar removal on the quality of

life of individuals at three-months postoperatively, assessed

by both OHIP-14 (mean 7.78, SD 5.77) and OHRQoLUK

(mean 53.02, SD 9.94) and at six-months postoperatively

(OHIP-14, mean 1.07, SD 4.15; OHRQoLUK, mean 54.36,

SD 10.08).

Risk of bias (quality) assessment

In general, most of the studies included were non-rand-

omized and the quality of these papers was high. Four of

the 11 non-randomized studies in this review received the

maximum score of 9 points [13, 15, 16, 18] according to

the NOS scores. Four studies scored 7 points [4, 7, 14, 23],

which was the lowest score given to any study. These results

are presented in Table 2. Regarding the randomized stud-

ies, one of these evaluated the changes in OHRQoL follow-

ing third molar surgery with either oral administration or

submucosal injection of prednisolone [21], while the other

evaluated the effect of ice pack therapy on OHRQoL fol-

lowing third molar surgery [22]. Both had an unclear risk of

bias as they provided insufficient detail regarding treatment

Fig. 1 Flow diagram showing the article selection process

Quality of Life Research

1 3

Tab

le 1

C

har

acte

rist

ics

of

studie

s in

cluded

in t

he

syst

emat

ic r

evie

w

Countr

y (

sam

-

ple

siz

e)

Stu

dy d

esig

nG

ender

Age

[mea

n

yea

rs (

SD

)]

Surg

ery

Dru

g t

her

apy

pro

toco

l

Post

oper

ativ

e

com

pli

cati

ons

No o

per

ators

Foll

ow

-up

OH

RQ

OL

index

Mal

e (%

)F

emal

e (%

)

McG

rath

(2003a)

[13]

Chin

a (9

3)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

26 (

28)

67 (

72)

26 (

8)

24**

One

man

-

dib

ula

r th

ird

mola

r

Anal

ges

ics

Tri

smus,

swel

ling,

dysa

esth

esia

,

bru

isin

g

n/a

7 d

ays

OH

IP-1

4 a

nd

OH

QoL

UK

-16

McG

rath

(2003b)

[ 14

]

Chin

a (8

8)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

24 (

27)

64 (

73)

26 (

7)

24**

One

man

-

dib

ula

r th

ird

mola

r

Anal

ges

ics

n/a

n/a

6 m

onth

sO

HIP

-14 a

nd

OH

QoL

UK

-16

Shugar

s et

 al.

(2006)

[ 15]

EU

A (

63)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

25 (

40)

38 (

60)

21 (

19.2

)**

All

thir

d m

ola

rsT

opic

al

min

ocy

clin

e

(1 m

g)

n/a

n/a

14 d

ays

OH

IP-1

4

Dee

pti

et 

al.

(2009)

[16]

India

(72)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

42 (

58.3

)30 (

41.6

7)

26.5

Unil

ater

al

hori

zonta

l

impac

ted

man

dib

ula

r

thir

d m

ola

r/

asym

pto

mat

ic

Ibupro

fen

n/a

n/a

7 d

ays

OH

IP-1

4 a

nd

OH

QoL

UK

-16

Wij

k e

t al

.

(2009)

[4]

Net

her

lands

(50)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

22 (

44)

28 (

56)

26 (

6.3

) m

ale

25 (

9.9

) fe

mal

e

Impac

ted m

an-

dib

ula

r an

d/

or

max

illa

ry

thir

d m

ola

r

n/a

Pro

longed

ble

edin

g,

absc

ess,

alveo

liti

s, d

is-

turb

ed w

ound

hea

ling

n/a

7 d

ays

OH

IP-1

4

Bra

dsh

aw e

t al

.

(2012)

[17]

US

A (

60)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

29 (

48)

31 (

52)

21.9

**,

20.2

–24.7

*

All

thir

d m

ola

rsA

nal

ges

ics

n/a

n/a

3 m

onth

sO

HIP

-14 a

nd

OH

QoL

UK

-16

Kie

ffer

et 

al.

(2012)

[ 18]

Net

her

lands

(97)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

45 (

46.4

)52 (

53.6

)26.2

mal

e

25.0

fem

ale

One

impac

ted

thir

d m

ola

r

n/a

Absc

ess,

alv

e-

oli

tis

n/a

30 d

ays

OH

IP-1

4

Neg

reir

os

et a

l.

(2012)

[7]

Bra

zil

(86)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

38 (

44.2

)48 (

55.8

1)

24.9

(7.6

)2 t

hir

d m

ola

rs

from

the

sam

e

side

No m

edic

atio

ns

n/a

17 d

ays

OH

IP-1

4

Quality of Life Research

1 3

n/a

not

avai

lable

, R

CT

ran

dom

ized

cli

nic

al t

rial

, n-R

CT

non-r

andom

ized

cli

nic

al t

rial

*IQ

inte

rquar

tile

ran

ge,

25th

–75th

per

centi

le

**M

edia

n

Tab

le 1

(c

onti

nued

)

Countr

y (

sam

-

ple

siz

e)

Stu

dy d

esig

nG

ender

Age

[mea

n

yea

rs (

SD

)]

Surg

ery

Dru

g t

her

apy

pro

toco

l

Post

oper

ativ

e

com

pli

cati

ons

No o

per

ators

Foll

ow

-up

OH

RQ

OL

index

Mal

e (%

)F

emal

e (%

)

Kaz

anci

oglu

et a

l. (

2014)

[ 19]

Turk

ey (

60)

n-R

CT

(co

n-

troll

ed b

efore

and a

fter

study)

32

28

22.6

(2.3

)B

ilat

eral

impac

ted

man

dib

ula

r

thir

d m

ola

r

Am

oxic

illi

n

(1000 m

g);

nap

roxen

sodiu

m

(550 m

g);

anal

ges

ic

Sw

elli

ng

17 d

ays

OH

IP-1

4

Kaz

anci

oglu

et a

l. (

2013)

[20]

Turk

ey (

60)

n-R

CT

(co

n-

troll

ed b

efore

and a

fter

study)

32

28

22.6

(2.3

)O

ne

impac

ted

man

dib

ula

r

thir

d m

ola

r

Am

oxic

illi

n

(1000 m

g);

nap

roxen

sodiu

m

(550 m

g);

anal

ges

ic

Sw

elli

ng

17 d

ays

OH

IP-1

4

Ibik

unle

et 

al.

(2016a)

[21]

Nig

eria

(186)

RC

T

69 (

37.1

)117 (

62.9

)28.1

(7.4

)O

ne

man

-

dib

ula

r th

ird

mola

r

Pre

dnis

olo

ne

(40 m

g);

amoxic

illi

n

(500 m

g);

met

ronid

azole

(200 m

g);

ibupro

fen

(200 m

g)

n/a

n/a

7 d

ays

OH

IP-1

4

Ibik

unle

(2016b)

[22

]

Nig

eria

(128)

RC

T

44 (

34.4

)84 (

65.6

)28.8

One

man

-

dib

ula

r th

ird

mola

r

Pre

dnis

olo

ne

(40 m

g);

amoxic

illi

n

(500 m

g);

met

ronid

azole

(200 m

g);

ibupro

fen

(200 m

g)

n/a

17 d

ays

OH

IP-1

4

Bra

imah

et 

al.

(2016)

[23]

Nig

eria

(135)

n-R

CT

(unco

n-

troll

ed b

efore

and a

fter

study)

63 (

46.7

)72 (

53.3

)24.4

fem

ale

25.3

mal

e

One

impac

ted

man

dib

ula

r

thir

d m

ola

r

Ibupro

fen

(400 m

g);

Am

oxil

/Cla

-

vula

nic

aci

d

(625 m

g)

n/a

114 d

ays

OH

QoL

UK

-16

Quality of Life Research

1 3

allocation, blinding of outcome assessment, and intention-

to-treat analysis. None were double-blind.

Meta-analysis results

Meta-analyses were carried out to compare the change in

quality of life of individuals between the preoperative period

and postoperative periods (1, 2, 3, 4, 5, 6, 7, and 30 days).

The OHIP-14 mean score on the first postoperative day

(POD) was 17.57 (95% CI 11.84–23.30) higher than the pre-

operative period. There was no difference in the patients’

perceptions regarding the impact of the surgical procedure

between the second and third POD (p = 0.682), as well

between the third and fourth POD (p = 0.121). On the sixth

POD, the mean score did not present a significant differ-

ence when compared to the mean score for the preoperative

period (Fig. 2). However, on the seventh POD, the qual-

ity of life as assessed by the OHIP-14 became worse again.

Considering the impact assessed with the OHRQoLUK, the

patients reported no difference in scores between the base-

line and 7th day postoperatively (Fig. 3).

Only two studies measured the quality of life at 30 days

after third molar surgery, and both of these used the OHIP-

14 [14, 18]. On the thirtieth POD, OHIP-14 scores were not

different from those found for the baseline (p = 0.599).

Concerning the impact of surgery on quality of life by

domains, “physical pain” affected 91% of individuals (95%

CI 0.85; 0.94) and was the most scored domain, while the

“handicap” domain was the least scored for the subjects, at

61% (CI 0.16; 0.92) (Fig. 4).

Discussion

To assess the impact of third molar surgery on individuals’

quality of life, the studies included in this review applied the

OHRQoL instruments OHIP-14, and OHRQoLUK instru-

ments. Concerning scoring systems, the higher the OHIP-14

score, the greater the impact on quality of life. Contrary to

this, the lower the OHRQoLUK score, the greater the impact

on quality of life. Despite this methodological difference,

both instruments were shown to be efficient in assessing the

impact on the individuals’ quality of life in all of the evalu-

ated postoperative periods, presenting similar results which

were moreover in agreement with other findings [15].

The present systematic review revealed that individu-

als submitted to third molar removal had increased total

scores on the OHIP-14 and decreased total scores on the

OHRQoLUK 1 day after the surgical procedure, suggesting

that there was a considerable negative impact on OHRQoL

in the immediate postoperative period. Investigations have

previously shown that significant alterations in quality of

life can occur on the first day after third molar removal [7,

15, 24–26]. This finding might be explained due to damage

to soft and hard tissues because of the surgical procedure as

well as possible complications such as trismus, swelling, in

addition to pain on account of the third molar surgery [4,

5, 27].

Over the follow-up period, significant improvements in

the quality of life were observed between the first postop-

erative day and subsequent evaluated postoperative days.

The results suggest that the procedure significantly affects

quality of life during the first five PODs, with no difference

between baseline and the sixth POD, as assessed by OHIP-

14. However, the data from the OHIP-14 illustrated a reduc-

tion in OHRQoL score on the seventh POD. It is possible

that during the early days after surgery, less inflammation

occurred than at 7 days [28]. Moreover, although not clini-

cally evident, from 7 to 10 days after extraction, mucosal

healing may be impaired by food or hematoma trapped under

the flap [29], which may cause some discomfort to patients.

However, the methodological heterogeneity adopted by the

various authors did not allow meta-analyses to verify the

impact of third molar surgery on quality of life immediately

after the seventh postoperative day to be performed.

When the quality of life was evaluated by the

OHRQoLUK index, although there was an impact observed

between the seventh POD and baseline, this difference was

not statistically significant, suggesting a full recovery of

the subjects. In part, this may reflect different domains and

questions probed by these different questionnaires. While

OHIP-14 focuses predominantly on negative effects, the

OHRQolUK instrument measures both positive and nega-

tive dimensions of OHRQoL [30].

When the impact on quality of life was separately ana-

lyzed for each domain, the “physical pain” domain was the

most recorded by the patients (91%). These present findings

reveal that pain seems to be the primary reason for the deteri-

oration of the quality of life after third molar surgery, mostly

on the day immediately postoperative [5] and decreasing

linearly over the course of follow-up, corroborating other

findings [24–26, 30]. These results may form as a source

of information for clinical planning when considering the

prescription of analgesics to recover OHRQoL more quickly.

For instance, the selection of the most appropriate surgical

protocol [31, 32] and the choice of therapeutic alternatives,

such as the use of acupuncture [33] and/or hilotherapy [34],

seems to be a contributory factor in pain reduction and, con-

sequently, is important in minimizing negative impacts on

an individuals’ quality of life after third molar removal [35].

The other more committed domains were “functional

limitations” (76%), “physical disability” (75%), “social

disability” (71%), “psychological discomfort” (70%), and

“psychological disability” (69%). The lowest domain scored

was “handicap” (61%), which is likely related to functional

disability and to the performance of daily tasks. Such results

Quality of Life Research

1 3

Tab

le 2

T

he

New

cast

le–O

ttaw

a S

cale

(N

OS

) fo

r as

sess

ing t

he

qual

ity o

f non-r

andom

ized

stu

die

s

a Age

gro

up e

stab

lish

ed f

or

com

par

abil

ity a

mong p

atie

nts

subm

itte

d t

o t

hir

d m

ola

r ex

trac

tion:

less

than

18 y

ears

old

; 18–45 y

ears

old

; m

ore

than

45 y

ears

old

b S

elf-

adm

inis

tere

d o

r in

terv

iew

er-a

dm

inis

tere

d Q

ues

tionnai

re (

1 s

tar)

c Adeq

uac

y o

f th

e fo

llow

-up l

ength

: Im

pac

t of

thir

d m

ola

r su

rger

y o

n t

he

qual

ity o

f li

fe w

as a

sses

sed a

t a

min

imum

of

seven

post

oper

ativ

e day

s (1

sta

r)

Yea

r, a

uth

or

Non-R

TC

stu

die

sT

ota

l

qual

ity

score

Sel

ecti

on

Com

par

abil

ity

Ass

essm

ent

of

outc

om

e

Rep

rese

nta

-

tiven

ess

of

the

pat

ients

subm

it-

ted t

o t

reat

men

t

of

inte

rest

Sel

ecti

on o

f th

e

pat

ients

subm

it-

ted t

o t

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con-

trol

trea

tmen

t

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erta

inm

ent

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tic

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on

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onst

rati

on

that

outc

om

e of

inte

rest

was

not

pre

sent

at s

tart

of

study

Com

par

abil

ity

bet

wee

n p

atie

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subm

itte

d t

o

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d m

ola

r

extr

acti

on—

mai

n f

acto

r:

agea

Com

par

abil

-

ity b

etw

een

pat

ients

in d

if-

fere

nt

trea

tmen

t

arm

s—se

cond

-

ary f

acto

r:

num

ber

of

thir

d

mola

r re

moved

Ass

essm

ent

of

outc

om

e w

ith

indep

enden

cyb

Adeq

uac

y o

f

the

foll

ow

-up

length

(to

ass

ess

outc

om

e)c

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to f

oll

ow

-

up a

ccep

table

(les

s th

an 1

0%

and r

eport

ed)

Bra

imah

et 

al.

(2016)

[23]

★★

★★

★★

★7

Kaz

anci

oglu

et a

l. (

2014)

[ 19]

★★

★★

★★

★★

8

Kaz

anci

oglu

et a

l. (

2013)

[ 20]

★★

★★

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Bra

dsh

aw e

t al

.

(2012)

[17]

★★

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Kie

ffer

et 

al.

(2012)

[ 18]

★★

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reir

os

et a

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(2012)

[7]

★★

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Chopra

et 

al.

(2009)

★★

★★

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Van

Wij

k e

t al

.

(2009)

[4]

★★

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s et

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(2006)

[ 15]

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McG

rath

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McG

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[ 14

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Quality of Life Research

1 3

Fig. 2 Differences of impact on the quality of life of patients between preoperative period (day 0) and postoperative days (day 1, 2, 3, 4 ,5, and 6)

Quality of Life Research

1 3

highlight the importance of preoperative and postoperative

care [35]. Moreover, detailed recommendations inform-

ing the patients and providing them with standard written

information concerning the required postoperative behavior

represent important factors that could affect the OHRQoL in

the postoperative period [36].

Several studies have addressed the domains of a patients’

quality of life individually, such as anxiety and stress, in

relation to surgical practice [37, 38]. Although in the dental

field oral-maxillofacial surgery has proven to be the treat-

ment that causes greatest anxiety levels [39], other domains

are indispensable to form conclusions regarding the quality

of life, as it is a multidimensional construct.

In a qualitative study using Twitter, a social media plat-

form, to collect real-time data about third molar experiences

that might impact quality of life, the authors suggested pain

was the most frequently reported impact [40]. In this review,

most of the studies included asymptomatic patients, suggest-

ing that the quality of life on the preoperative day was not

influenced by the condition. In the same way, many studies

were not included in the present study because they did not

evaluate preoperative quality of life [41–45]. The authors

of this systematic review believe that studies using a longi-

tudinal design could provide a better understanding of the

factors that influence the OHRQoL scores of individuals

who have undergone third molar removal surgery.

These findings provide useful information for oral and

maxillofacial practice. First of all, to educate patients about

possible symptoms may reduce the anxiety caused by the

surgical procedure. In addition, withdrawal from work or

school activities for 4 days should be recommended. Nev-

ertheless, some results of the present study should be care-

fully interpreted as some of the analyses, although showing

statistically significant outcomes, exhibited a high degree

of heterogeneity. This heterogeneity might be associated

with the difference between the methods applied in each

of the included studies (e.g., non-standardized regimen of

postoperative medications, variations of third molar posi-

tion, surgeon experience, and the number of operators whom

performed the surgeries). Another possible source of hetero-

geneity that can be found among the included studies stems

from the fact that the symptomatology of the third molars

at baseline was not considered in this systematic review.

Although the authors from the present review have not eval-

uated symptomatic and asymptomatic patients separately, it

is assumed that patients who experienced some symptoms,

such as pericoronitis, [14] modulate their response to the

quality of life questionnaires differently compared to those

who did not have a previous experience of inflammatory.

Some limitations were observed in the present system-

atic review. A non-standardized number of removed teeth

per patient was observed among the included studies in this

review. The impact of surgery on quality of life may have

been different for those submitted to multiple extractions

could experience a greater negative impact when compared

to those who had only one-third molar removed.

Fig. 3 Differences of impact on the quality of life between the preoperative period and the seventh postoperative day, according to OHIP-14 and

UKOHQol-16

Quality of Life Research

1 3

In general, the included studies presented good quality

regarding the risk of bias assessment. The main limitation

of this review was associated with an inherent lack of stand-

ardization in the methodology of the included primary stud-

ies. Thus, few studies were included in the meta-analyses,

since there was a great difference in the follow-up periods.

Moreover, this systematic review included studies with dif-

ferent designs, and few randomized controlled studies were

noted. Despite this limitation, considering that our objective

was not to evaluate different interventions but to investigate

an outcome (quality of life) for the same type of interven-

tion (third molar removal surgery), we considered that the

inclusion of different study designs would generate more

comprehensive and useful results. However, these results

should not be understood as conclusive evidence regarding

quality of life after third molar surgeries, but rather as rel-

evant information to guide future studies. Thus, conducting

studies with greater follow-up periods (more than 7 days)

Fig. 4 Frequency of impact of third molar removal on quality of life measured by OHIP-14, according to each domain

Quality of Life Research

1 3

and studies using validated questionnaires, especially the

OHRQoLUK index and the OHIP-14, may in the future,

generate evidence-based recommendations with external

validity.

Taking into account the available data, this systematic

review revealed that the highest negative impact on quality

of life of individuals submitted to third molar surgery was

observed on the first day postoperatively, and decreased over

the follow-up period, with physical pain the most scored

domain.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict of

interest.

Ethical approval All studies included in this systematic review were

in accordance with the ethical standards of the institutional and/or

national research committee, with the 1964 Helsinki Declaration and

its subsequent amendments or comparable ethical standards.

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