Mandibular third molar removal: patient preferences, assessments of oral surgeons and patient flows

Mandibular third molar removal is one of the most common treatments conducted at oral and maxillofacial surgery clinics in Sweden. During the 1980's and 1990's, 20-25,000 mandibular third molars were removed annually which represents about 60% of the total operation volume. Removals performed in private specialist clinics and general dental clinics are not included in these figures. The aims of the present studies on mandibular third molars were to: 1) study values that reflect patients' preferences about possible outcomes of removal and non-removal; 2) make comparisons between Sweden and Wales with respect to patient's preferences; 3) study assessments of oral surgeons' indications for molars to be removed; 4) describe patient flows in the care process of removal. The multi-attribute utility (MAU) method was used to quantify patients' preferences about outcomes following removal and non-removal. Whilst there were clear cultural and economic differences between the Swedish and the Welsh, there was a high degree of correlation in patients' ranking of the different outcomes for patients from the two countries (rs = 0.93, P<0.001). Generally, situations describing the outcomes of non-removal had a higher ranking than those describing the outcomes of removal i.e. patients seemed to prefer non-removal. Oral surgeons at seven specialist clinics registered data for 666 patients i.e. patient age and sex, the angular position and extent of eruption of the molar and whether or not there was an associated disease related to the molar proposed for removal. The indication for the removal was assessed on a Visual Analogue Scale (VAS), and the recorded results found to show a great variety. The mean VAS for removal of molars without disease was significantly lower than that for molars with associated disease. The differences between the mean VAS for molars with one disease compared with molars with two or three diseases were not significant. The patients' age was the only factor that had a significant effect on the assessment of the indication for molars without disease. The indication was higher for patients of the youngest age group than for patients of the oldest age group (P<0.05). In four specialist units in southern Sweden, the patient flows (the number of visits and what the visits comprise of) was registered for 361 patients. All details were recorded from arrival of the referral to the unit to performed mandibular third molar surgery. Eight different patient flows were found. The number of patient visits varied from one to three. For about 60 percent of the patients, attached radiographs to the referral were considered not appropriate and had to be completed, e.g. to be retaken. For a minority of the patients, the radiographic examination was completed at the radiological clinic included in the specialist unit and, in the oral and maxillofacial clinic for the others. The number of patient visits seemed not to depend on whether the attached radiographs were judged to be appropriate or not.

Patient preferences seem to be more stable than the preferences of oral surgeons across the boundaries. Patients prefer outcomes of third molar non-removal as compared to outcomes following removal. Different patient flows may influence the cost-effectiveness in mandibular third molar surgery.