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ORIGINAL RESEARCH Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 3  |  Page : 208-212
Pathosis associated with radiographically normal follicular tissues in third molar impactions: A clinicopathological study


1 Department of Oral and Maxillofacial Surgery, School of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Pathology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
3 School of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran

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Date of Submission03-Jun-2007
Date of Decision18-Sep-2007
Date of Acceptance20-Sep-2007
 

   Abstract 

Background: The follicular tissue around impacted third molars has a potential to develop pathosis. However, it is generally assumed that the absence of abnormal radiolucency indicates the presence of a normal follicle.
Aims: The aim of this study was to investigate abnormalities associated with radiographically normal follicular tissue of third molar impactions.
Materials and Methods: One hundred eighty-five impacted third molars from 170 patients with no signs of abnormal radiolucency (follicular space <3 mm) were used for this study. Follicular tissues of the relevant teeth were collected. Specimens were fixed in 10% formalin and stained routinely with hematoxilin and eosin to be independently examined by two pathologists. A diagnosis was registered only when the results from both pathologists were in concordance. Clinical details for each patient were registered in WHO standard forms to undergo chi-square statistical analysis.
Results: Fifty-three per cent of the specimens had developed pathosis. The incidence of pathosis was higher in the age group of 20-30 years, in men compared to women and in the mandible compared to the maxilla.
Conclusion: The findings of this study suggest that radiographic appearance may not be reliable in the diagnosis of pathosis in follicular tissue as a surprisingly high rate of pathosis was found in the absence of any radiographically detectable sign.

Keywords: Impaction, pericoronal pathosis, pericoronal radiolucency, third molar

How to cite this article:
Mesgarzadeh AH, Esmailzadeh H, Abdolrahimi M, Shahamfar M. Pathosis associated with radiographically normal follicular tissues in third molar impactions: A clinicopathological study. Indian J Dent Res 2008;19:208-12

How to cite this URL:
Mesgarzadeh AH, Esmailzadeh H, Abdolrahimi M, Shahamfar M. Pathosis associated with radiographically normal follicular tissues in third molar impactions: A clinicopathological study. Indian J Dent Res [serial online] 2008 [cited 2019 Oct 19];19:208-12. Available from: http://www.ijdr.in/text.asp?2008/19/3/208/42952
The removal of embedded third molars constitutes a large proportion of oral surgery procedures in the dental office. There are reports from studies worldwide suggesting a recent increase in the incidence of third molar impactions. [1],[2] The radiolucent area (namely follicular tissue) around these teeth has a potential to develop pathological conditions. However, there has been no internationally accepted consensus in dental literature to date on clinical criteria to differentiate between normal and pathological conditions of follicular tissue based on the radiographic features around impacted third molars. [3] Previous studies suggest that normal pericoronal radiolucency is in the range of 2-3 mm although there is limited scientific data attesting the validity of this assumption. [4],[5],[6],[7] Several recent studies have demonstrated considerable pathosis in cases with clinically normal radiolucency. [8],[9],[10],[11],[12] These recent studies have indicated that the incidence of pathosis in follicular tissues is higher than generally perceived from radiographic examination alone. This is especially notable since important pathological conditions such as ameloblastomas, odontogenic keratocysts or dentigerous cysts have been observed in the follicles which have the potential to develop into more serious complications. Despite recommendations from the National Institutes of Health (NIH) Consensus Development Conference [13] on wisdom tooth removal indications, many authors [14],[15],[16] have questioned the routine removal of impacted third molars attributing it to the current lack of knowledge about incidence and/or odds of pathosis in normal pericoronal tissues. There seems to exist some degree of perplexity among dental professionals in dealing with asymptomatic and radiographically normal impacted wisdom teeth.

The aim of this study was to investigate abnormalities associated with radiographically normal pericoronal soft tissue of third molar impactions.

This may help improve our knowledge about the epidemiology of diseases associated with third molar impactions and improve our clinical management of these teeth to minimize false interpretations and clarify our definition of normal third molar impactions.


   Materials and Methods Top


We initially considered the enrollment of patients who referred to the Maxillofacial Department Clinic in the School of Dentistry, to have their impacted third molars removed for a variety of reasons. The study protocol was subsequently reviewed by the corresponding University Review Board and was approved by the Special Committee for Ethics and Humanity. Prior to entry into the research program, informed consent was obtained separately and in special forms provided by the local Ethics Committee from each patient.

Patients underwent preliminary panoramic radiography to determine if they met the study criteria. Inclusion criteria were the need to have at least one impacted third molar and to have pericoronal radiolucency £2.9 mm in any dimension. All the panoramic radiographs were taken with Promax Planmeca (Finland) and the magnification factor was 1.2. Although all the reported measurements were adjusted and standardized according to the magnification factor of the panoramic X-ray machine used in this study, this issue should be addressed in future studies especially with regard to the interpretation of data. Our exclusion criteria for the study were follicular space >3 mm and teeth with follicular tissue insufficient for histopathology examination.

Initially, 185 impacted third molars from 170 patients qualified to be included in the study, and were extracted routinely (in some patients more than one tooth was removed). Specimens from the pericoronal soft tissue of the relevant teeth were then collected and fixed in 10% formalin and routinely stained with hematoxylin and eosin. However, 14 out of 185 specimens were lost due to various reasons during the preparation of the histological slides.The remaining 171 slides were independently studied by two pathologists, who were blinded to each other's diagnosis. A diagnosis was registered only when both pathologists' results were in concordance while in cases with inconsistent outcomes, a consensus diagnosis was arrived at after joint review. The observed pathological changes are shown in [Table 1] and were of several kinds. The presence of a fibrous connective tissue wall with a few layers of odontogenic, stratified squamous epithelium indicated the presence of a dentigerous cyst [Figure 1]. Existence of ameloblastic tumor cells with a reverse polarity nucleolus in a fibrous connective tissue was diagnosed as an ameloblastoma [Figure 2]. The presence of accumulated epitheloid and giant cells encapsulated by a layer of lymphocytes indicated a foreign body granulome; the foreign bodies were of unknown origin. Colonization of Actinomyces in an inflammatory granulation tissue was considered suggestive of sulfur granules. The diagnosis of hyperplasic nonkeratinized squamous epithelium was made when the epithelium demonstrated epithelial thickening over the underlying connective tissue due to inflammation.

In this study, all the above diagnoses are referred to as pathological changes or alterations. Whereas inflammatory follicles demonstrated the infiltration of chronic, nonspecific inflammatory cells, follicles demonstrating only infiltration of inflammatory cells were not categorized as an independent pathological case. The clinical details for each patient including age, sex and location of the lesion were recorded in WHO standard forms and were correlated with the histopathological findings to undergo statistical analysis using SPSS.12 and chi-square analysis to determine significance associated with each factor.


   Results Top


Forty-eight male and 123 female specimens were examined for this study from patients in the age group of 15 to 50 years. Surprisingly, we found that 53% of the specimens, i.e., 92 follicles out of 171 samples with the normal radiolucency range, had undergone various pathological changes [Table 1]. Dentigerous cysts constituted the majority of the detected pathological alterations, being detectable in 65 (38%) out of 171 follicular samples. Ameloblastomas were the second-most pathological change observed in ten (5.8%) follicular specimens. Next in the list of frequently observed pathological changes were sulfur granules (4%), followed by foreign body granulomes and hyperplasic, nonkeratinized, squamous epithelium (3%). We found a statistically significant male preponderance for these pathological changes (P = 0.000). While 38/48 follicular specimens (79%) from male patients were pathological, only 53/123 specimens (43%) from female patients were pathological. Furthermore, a gender distribution analysis revealed the male-to-female ratio for pathosis to be 1.8:1.

Although we found a statistically significant increase in the rate of pathosis with increasing age, the correlation was stronger in the 20-30 years' age group (P = 0.001, [Table 2]) in which most of the pathological changes were observed. A similar statistical significance (P = 0.000) was seen for pathosis in inflammatory follicles vs noninflammatory follicles. We found that while 84/104 (80%) inflammatory follicles showed pathological changes, only 8/67 (11%) noninflammatory dental follicles showed pathological changes. A site-wise analysis also showed a significant incidence of pathosis in the lower jaw (vs upper) - specifically, the mandibular right and mandibular left (vs other sites, [Table 3]).


   Discussion Top


One of the most common challenging decisions taken by dental professionals is the decision about asymptomatic, impacted third molars. Despite recommendations from the NIH Consensus Conference on third molar removal, [13] there are still controversies over the clinical judgment to differentiate between radiolucency ranges of normal and pathological conditions in soft tissue around embedded wisdom teeth. In this regard, some times, even oral surgeons find it difficult to establish a consistent judgment policy. [14],[15],[16] Although pathological involvement associated with impacted third molars is a clear indication for their removal, [17] prophylactic extraction remains controversial. Some authors [15],[16],[17],[18],[19],[20] have suggested prophylactic removal as a precautionary measure to prevent further complications due to retained impactions; others [21],[22],[23],[24],[25],[26] have undermined the scientific validity of this model, arguing that this procedure may not always be necessary. However, the latter assumption is likely to be due to several reasons. First, it is likely that by removing most pathologically associated wisdom teeth at early ages, fewer cases of diseased impactions are left to be diagnosed at older ages. Secondly, some of the pathological conditions may involute and therefore, not progress to clinically important lesions. Mercier et al , [22] suggested that before making any decision regarding impacted wisdom teeth, the risk-benefit ratio of both removal and retention of the teeth should be reviewed. They concluded that a strong indication should be followed by a strong contraindication to its removal.

Brickley and Shepherd [27] proposed a computer-based neural network as an auxiliary measurement to help clinicians in third molar referral decisions.

One of the problems that we, as clinicians, face is that there is limited data available from studies [8],[9],[10],[11] with regard to pathological changes in radiographically normal follicles around wisdom teeth. This is despite previous attempts investigating pericoronal soft tissue pathosis in radiolucent lesions. [28] One disturbing finding from this study is that more than half of the specimens with radiographically normal follicular radiolucency had developed pathological entities. This surprisingly high rate of pathosis in normal radiolucencies of follicles has probably never been highlighted in any of the previous studies undertaken in a similar range, although few investigations in this regard have found comparatively lower incidences. [8],[9],[10] In a previous investigation by Baykul et al, the histological evaluation of follicles obtained from radiographically normal impacted third molars showed that almost half of the specimens had developed pathosis with cystic changes being the only observed pathological condition. [9] However, the histopathological evaluations in other investigations have detected multiple changes. While some studies [8],[9],[10] have reported dentigerous cysts as the only detected pathologic entity, others [11],[12] have shown a number of other changes too. In a histological investigation by Raprasitkul of unerupted third molar dental follicles, evidence indicative of odontogenic keratocysts and ameloblastomas as well as of dentigerous cysts was observed. [11] Furthermore, in a report by Leitner et al, a malignant low-grade fibrosarcoma was observed in an impacted third molar without any clinical evidence of a follicular lesion. [12] That was the first description of a fibrosarcoma in an impacted third molar dental follicle. However, our data describing different changes in follicular tissue around third molars is very limited as many surgeons discard the follicular tissue after extraction rather than submitting it for histopathological evaluation, thus losing a potential source of pathosis without examination. In the current study, a host of pathological changes were observed. Although dentigerous cysts constituted the majority of the observed pathological changes, ameloblastomas were the second most frequently pathological change detected. Sulfur granules, hyperplasic squamous epithelium as well as foreign body granulomes comprised the rest of the pathological changes detected in our study. Similar to the findings of previous studies, the rate of pathosis development has also varied considerably among various investigations. Glosser and Campell found pathological changes in 32% of impacted third molar follicles, [8] Adelsperger et al, detected pathosis in 34% [10] while in another study by Rakprastikur, 59% of follicles had developed pathosis. [11] Baykul et al, have also described a pathosis rate of 50% in dental follicles of asymptomatic, lower impacted third molars. [9] Similar to our study, neither of these follicles demonstrated any pathosis-related radiographic evidence of follicular lesions and the only difference in their radiographic appearance was a varying size in the range of £2.9 mm. The results of our study compare favorably with those of others in that the dentigerous cyst is the most frequent pathological entity detected in clinically normal dental follicles of impacted third molars. The proportion of dentigerous cysts relative to all the pathological changes seen in impacted third molar follicular tissues varied from >70% in our study to 86% in others [11] and 100% in many studies. [8],[9],[10]

In the current investigation, follicular tissue pathosis was also studied in relation to the tooth site. We found significantly more pathological changes in the lower jaw than in the upper, particularly, in the mandibular right and mandibular left impacted third molars vs other sites. These findings are consistent with several studies, [8],[11] but not with another study that found no significant predilection for any tooth site. [10]

Moreover, a gender-wise distribution analysis of the histopathological diagnosis of pathosis revealed a male preponderance. Although a similar male preponderance has been reported by several studies, [9],[10] the reason for this gender difference is not clear. Some studies have suggested that this might be due to prophylactic extraction of third molars in female patients because of their small jaw size. [29] However, even studies on prophylactic removal of radiographically normal follicles have demonstrated the same male preponderance. [10],[11]

Most of the radiographically hidden pathologies in dental follicles in the current study were associated with a young age group (20-30 years). Previous investigations have also found a higher incidence of pathological changes in patients past their second decade of life. Considering these facts and based on findings from the current study indicating a high rate of pathosis in youth (20-30 years) in asymptomatic third molars, we recommend that all third molar impactions in young people, be subject to prophylactic removal.

Tulloch et al, [30] put forward the low cost-effectiveness of prophylactic surgery for all the third molar impactions. They mentioned that the annual cost of prophylactic removal was much higher than that of removal of only diseased third molars. Our recommendation stated above intends to minimize the false retention of diseased impactions by removing primarily the follicles which most frequently manifest unnoticed pathologic condition (i.e. in young people) while simultaneously improving the cost-effectiveness of the issue. In this way, we may target impactions primarily in age groups with a high risk of developing pathosis, that may be difficult to diagnose.

Unfortunately, it is generally believed in the dental community that the absence of abnormal radiolucency indicates a healthy dental follicle with absence of pathosis, while findings from this study and from previous reports [8],[9],[10],[11] contradict this belief. Such a belief in the dental community can trigger a sequence of misdiagnoses ending in the unfavorable clinical management of patients.

There have been some reports on the association between chronic facial pain and impacted third molars. It has been reported to be a common complaint particularly in young adults. [1] A study by Samsudin and Mason [31] found that 73% of patients waiting for third molar surgery suffered from pain. Others [32],[33] have also found somewhat similar results. The results from the current study found that most (80%) of the follicles with inflammatory condition had also developed pathosis. Although this finding requires further investigation, it may still be helpful to medical professionals in differential pain diagnosis in the facial region especially in correlating vague pain of unknown origin with impacted wisdom teeth.

Although we found a higher incidence of pathosis than expected, the implications of this finding are not yet fully known. As few studies have examined this issue, we recommend further comprehensive investigations into dental follicles with smaller, yet normal radiolucencies. This may help clinicians in decision-making about wisdom teeth and may help to provide better patient oral care.

The overall results gained from the current study indicate that clinical judgment based solely on radiographic appearance may be quite deceptive and could jeopardize our ultimate goal as dental professionals in providing high-quality oral care. It is worth stating here that perhaps, both definition and diagnostic value for pathosis in the dental follicle should be reconsidered. Indeed, new techniques like immunochemical or histomorphometric methods might provide further assistance in histological diagnosis of abnormalities associated with dental impactions. Presently, it does not appear possible to determine which radiographically normal impaction with histological evidence of pathosis will continue to be a clinically detectable lesion. The dental profession needs to consider all associated factors before formulating an evidence-based policy in the management of third molar impactions to deliver maximum long-term benefit through patients oral care.


   Acknowledgments Top


This study was conducted under aegis of the vice-chancellorship for research for Tabriz University of medical sciences, school of dentistry, and hereby is acknowledged.

 
   References Top

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Correspondence Address:
Ali Hossein Mesgarzadeh
Department of Oral and Maxillofacial Surgery, School of Dentistry, Tabriz University of Medical Sciences, Tabriz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.42952

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