ASSESSMENT OF PAIN AND TRISMUS AND DETERMINING THE DIFFICULTY LEVEL OF TOOTH EXTRACTION WITH MODIFIED PARANT SCALE Affiliation

Total number of pa ents included in this study were 266 (male 135 and female 131), age range from 18 to 34 years. Preopera ve diagnosis was made by clinical examina on and radiographs. Clinical examina on was done to determine pain, swelling and mucosal coverage of tooth whereas OPG and RVG were taken to assess the angula ons, level of tooth impac on and bony coverage of tooth. Standardized technique was used for tooth extrac on; buccal gu ering, adequate eleva on, reflec on of mucoperiosteal flap, crown sec oning and ostectomy. Evalua on of pain and trismus was done preopera vely, on first and third post opera ve day. SPSS version 16 was used to analyse the data. Chi square (x2) test and unpaired 't' test were done. Modified Parant Scale was used to evaluate the difficulty of tooth extrac on; Group I: forceps extrac on; Group II: ostectomy; Group Ill: ostectomy and crown sec oning; Group IV: difficult extrac on.


Methodology
Total number of pa ents included in this study were 266 (male 135 and female 131), age range from 18 to 34 years.Preopera ve diagnosis was made by clinical examina on and radiographs.Clinical examina on was done to determine pain, swelling and mucosal coverage of tooth whereas OPG and RVG were taken to assess the angula ons, level of tooth impac on and bony coverage of tooth.Standardized technique was used for tooth extrac on; buccal gu ering, adequate eleva on, reflec on of mucoperiosteal flap, crown sec oning and ostectomy.Evalua on of pain and trismus was done preopera vely, on first and third post opera ve day.SPSS version 16 was used to analyse the data.Chi square (x²) test and unpaired 't' test were done.Modified Parant Scale was used to evaluate the difficulty of tooth extrac on; Group I: forceps extrac on; Group II: ostectomy; Group Ill: ostectomy and crown sec oning; Group IV: difficult extrac on.

Results
When both preopera ve and postopera ve results were compared a er data analysis, pain was significantly reduced and significant inter incisal opening was achieved, in both the groups P > 0.05.The results were sta s cally not significant.

INTRODUCTION
Third molar extrac on has been and s ll is the most frequent opera on performed by oral and maxillofacial 1 surgeons both in private prac ce and in hospital se ngs.Third molar generally erupt between the age of 18 to 24 2 years though there is wide varia on in erup on dates.The rd average age for mandibular 3 molar erup on, in male is 3 approximately 3 to 6 months ahead of females.Some rd authors reported that the incidence of mandibular 3 molar Third molar extrac on is a clean contaminated surgery and the chances of postopera ve infec on is not more than 12 5%.The risk of wound infec on a er surgical removal of rd 13 3 molar is precisely low between 1 and 6%.Different classifica on systems has been introduced to assess the difficulty level of tooth extrac on but they are of minimal considered as complica ons.Careful surgical technique and scrupulous periopera ve care can minimize the frequency of complica ons and limit their severity.A thorough understanding of the complica ons associated with this procedure will enable the surgeon to counsel high risk pa ents, manage the complica ons appropriately, be cognizant of less common sequelae and the most effec ve 18 method of management.The postopera ve pain, swelling and trismus is always associated with reflec on of mucoperisoteal flap where as a smaller incision and minimal reflec on will result in minimal pain, swelling and This is a single operator study whereas all past studies were evaluated by different operators.In the work reported here, we evaluated pain and trismus in 266 pa ents who rd had undergone removal of mandibular 3 molars and evaluated the difficulty level of surgery on both responses.

METHODOLOGY
This cross sec onal study was performed in the Department of Oral and Maxillofacial Surgery, Faculty of Den stry, Biratnagar Hospital PVT LTD and Birat Medical College and Teaching Hospital, Biratnagar, Nepal from 2014 to June 2017.Informed wri en consent was taken from the pa ent and their legal guardians.The pa ents were informed clearly about the treatment procedure, the results, advantages, disadvantages and possible postopera ve complica ons.
Total of 266 pa ents, 135 male and 131 female with age ranging from 18 to 34 years were included in this study.Inclusion criteria were as follows; Asymptoma c tooth rd indicated for extrac on; 3 molar causing damage to the adjacent tooth, serial extrac on, orthodon c purpose, orthognathic surgery, Age: 18 years -38 years, impacted tooth and pa ents showing coopera on with the study.Orthopantomogram was taken as a standard and was advised to all the pa ents.Preoepra ve radiographs were taken to assess the difficulty level of surgery preopera vely according to Modified Parant Scale.
Difficulty of tooth extrac on was evaluated on MPS; Group I: forceps extrac on; Group II: ostectomy; Group Ill: ostectomy and crown sec oning; Group IV: difficult extrac on.The dura on of surgery from incision to last suture was 19,23,24 recorded a er every tooth extrac on.
Tooth extrac on was performed under local anaesthesia.Before tooth extrac on each and every pa ents were in pain and infec on free state.0.12% chlorhexidine mouth wash was given to each pa ent immediately before tooth extrac on.Standardized technique was used for tooth extrac on; buccal gu ering, adequate eleva on and reflec on of mucoperiosteal flap, crown sec oning and ostectomy.Pa ents were asked to strictly follow the postopera ve instruc ons given by the surgeon a er tooth.

RESULTS
Out of 266 pa ents, 135 (50.75%) were male and 131 (49.25%) were female (Table 1  Inter incisal distance should always be measured by the same surgeon to avoid observer bias.Pa ents had no wound infec on and other related complica ons a er tooth extrac on (simple or surgical) according to this study.Hence, postopera ve pain can be reduced and maximum mouth opening can be achieved with me culous ssue manipula on, administra on of analgesics, proper wound care by pa ent and regular follow-up.
The evalua on of pain is always subjec ve which is assessed MPS is considered to be rela vely more reliable according to most studies but it is also less reliable for clinical and 23 radiological parameters discussed above.
Pain is a useful clinical model for evalua on of analgesics a er tooth extrac on.Analgesics a er tooth extrac on always enhances the pa ents comfort, decrease the pain 28 and stress.
Some author reported that the most common impac on were ver cal followed by mesioangular, 42.92% and 36.94%respec vely and few reported that mesioangular over ver cal, 37.5% and 35% respec vely whereas our study revealed mesioangular 51.88% were most common 30,31 then ver cal 24.44% impac on.Some authors reported that the teeth with total mucosal and par al bony coverage 31 were 60.5% and 70% respec vely.According to our study most of the teeth were without mucosal and bony coverage, 60.53% and 66.17% respec vely.
Surgical difficulty was found to be more with those teeth which were in posi on C rather than posi on A and B.
Gulsun et al reported that the most common posi on of teeth were in posi on B and A, 52.90% and 31.44%respec vely whereas our study showed that the most common posi on of teeth were, posi on A and B, 60.53% and 36.47%Interincisal distance between Parant groups II, III, and IV postopera vely was more or less same.To evaluate postopera ve trismus these three Parant group represents same level of difficulty, hence these three groups has been denominated as surgical extrac on whereas interincisal distance in Parant group I was sa sfactory, hence this group has been denominated as simple or non surgical extrac on.
Whenever the pa ents are asked to open the mouth to measure inter incisal distance, the measurement differ in every follow up.Hence, normal distance may vary considerably in same pa ent.The values obtained by various clinicians is directly propor onal to the measuring device used: a vernier caliper may hold the mouth open wide to some extent whereas a measuring scale cannot hold the mouth open wide.The study showed that there was no significant difference between the results.We think that this study can be a base for further studies to examine the differences in postopera ve morbidity (pain and trismus) a er surgical or non surgical extrac ons.However, further study could be done with larger sample size and greater logis c support.

CONCLUSION
Pain and trismus both are directly propor onal to aggressiveness of the surgeon and difficulty of surgery.However, this study has tried to evaluate the results objec vely by comparing pre and post opera ve photographs and pa ent clinician interac on.Postopera ve pain and trismus was minimum a er simple or non surgical tooth extrac on cases (Group I) when compared to surgical extrac on (Group II to IV).Regardless of extrac on type, intensity of pain decreases and inter incisal distance st rd increases between 1 and 3 post opera ve day.According to our study the incidence of postopera ve pain and trismus among all the groups were more or less similar.Hence, no significant differences among the groups in the incidence of pain and trismus was found.

RECOMMENDATION
Further studies with more advanced technology and modern instruments can be done to obtain more accurate results.

4 , 5 impac
on is greater in females.The most commonly impacted tooth in oral cavity is rd mandibular 3 molar and of all impac ons 98% comprises rd 6,7 rd of mandibular 3 molars.The frequency of 3 molar impac on ranges from 18% to 70% which varies among different popula ons.The erup on of tooth depends upon the racial varia on, facial growth, arch length and tooth 8 rd size.The prevalence of 3 molar impac on ranges from 27-68.6% whereas few studies from the Gulf region have 9 revealed the prevalence to be 32-40.5%.Some author rd rd showed the prevalence of 3 molar impac on for, one 3 rd rd molar = 3-4%, two 3 molar = 8-11%, three 3 molars = 9rd 10,11 12% and four 3 molars = 73-77%.
is an unpleasant sensory and emo onal experience associated with actual or poten al ssue damage or described 20 in terms of such damage.Pain is always associated with tooth extrac on, suturing, type of impac on and opera ve 21 me.Trismus is a state or condi on where mouth opening is transient and it occurs due to tonic contrac on of muscles 22 of mas ca on.Trismus is directly propor onate to surgical tooth extrac on, the dura on of surgery, ostectomy and 21 crown sec oning.
st rdPa ents were asked to come on 1 and 3 POD for assessment of pain and to measure inter incisal distance.Visual Analogue Scale (VAS) was used to assess the pain intensity.Digital vernier calliper or measuring scale according to avaibility were used to measure inter incisal distance from incisal edge of the upper and lower right central incisors.Photographs were also taken for records.Results were arranged in tables.SPSS version 16 was used for data analysis.The evalua on was done by unpaired't' test.The result was considered significant when p value was <0.05.

28 using
visual analog scale that varies with individuals.The assessment of trismus is objec ve which is measured by determining inter inicsal distance using digital vernier caliper.Postopera ve morbidity like pain and trismus are related to difficulty of surgery.Thus, prostaglandins and other inflammatory mediators are released from membrane phospholipids as a 29 result of tooth extrac on (simple or surgical).Various indexes have been proposed and are used byrd clinicians to classify difficulty of impacted 3 molar 15 removal.There are three imaginary lines in the form of Both Winter's and Pell and Gregory classifica on are unreliable and are used less in clinical prac ce though these 15,19,21 methods are taught to most undergraduate students.
Agrawal M et al ISSN: 2542-2758 (Print) 2542-2804 (Online) Birat Journal of Health Sciences ). Mesioangular and Ver cal were the common impac on of all, 51.88% and 24.44% respec vely.Teeth in posi on A and posi on B were 60.53% and 36.47%respecvelywhereasteeth without Mucosal and Bony Coverage were 60.53% and 66.17% respec vely.Pa ents were pain free before tooth extrac on P value was TableII).Mean inter incisal distance and dura on of surgery in each parant groups are listed in Table (I, II, III and IV).Inter incisal distance before tooth extrac on was almost st same in all four Parant groups.On 1 POD inter incisal rd distance was more in group I then in group II, III and IV, on 3 POD also it was greater in group I then in group II, III and IV.Interincisal distance in group I did not show any significant change over me but in groups II, III and IV it varied significantly with me.Time taken for tooth extrac on was less in group I pa ents than in the other group pa ents and significantly higher in group IV when compared to other groups.Results were sta s cally not significant.

Table 2 : Number of pa ents and difficulty level of surgery (n=266) Table 2 : Difference in Intensity of Pain (VAS) with Period of Evalua on (n= 266)
ns = Not Significant.Significant cutoff value <0.05 Agrawal M et al