Third molar infections and their impact on systemic health- an awareness study among women degree college students of Udupi City, Karnataka, India
Introduction Third molars (wisdom tooth) are the last tooth to erupt at the age of 17–25 years and may partially erupt or remain impacted in the dental arch. Third molars irrespective of their eruption pattern are rarely disease-free and often can progress from a localized infection to severe complications involving the cervicofacial structures, within a span of few hours. Third molars that erupt in a functional position are often subjected to bacterial accumulation as maintaining the oral hygiene and health of the third molar is compromised due to the anatomical position. Thus, resulting in pathologies such as dental caries, pericoronitis, and periodontitis. Failure of a tooth to reach a normal functional position in the occlusion is termed impaction and has been associated with several pathologies such as infection, non-restorable carious lesions, periodontal pathology, root resorption, pericoronitis, cysts, and tumors. , Infections such as dental caries and pericoronitis in third molars are commonly seen in people aged 20–29 years and predominately in women. Untreated third molar infections can result in pain, oral swelling, and poor quality of life and it can progress from a local infection to the development of severe and even life-threatening complications. Etiological factors such as angulation of tooth, oral hygiene, systemic conditions such as diabetes, smoking and stress among women due to menstruation, fatigue, and exams are responsible for third molar infection. Treatment management third molar diseased tooth ranges from the extraction of the tooth, operculectomy, or restoration. Management of third molar free of pathologies or symptoms has not been reached, extra attention is required from clinicians and patients. Recognition of clinical presentation of the condition and referral to a dental provider who can diagnose and treat the disease would be crucial in improving patient outcomes. Radiographic examination is an essential aid in diagnosing pericoronitis as it can show the positions of erupting third molars if present. A panoramic radiograph is the best method to assess the presence and position of erupting third molars. Researchers have emphasized that the college years present a significant opportunity for developing positive health behaviors, as students experience independence for the first time. The habits formed by college students lay the groundwork for either long-term health benefits or an elevated risk of disease. Understanding women students' knowledge of oral health, their practices, and their awareness of preventive measures is crucial for designing targeted interventions to improve oral health outcomes in this demographic group. More emphasis must be given to educating people about the importance of their oral health and how they are required to maintain it to eliminate any possible focus of infection from the body. Hence the study aimed to determine the awareness regarding the third molar infection among women degree students. The objectives of the study were to determine the third molar health status among the study population and increase awareness about the third molar fitness among woman-degree college students. 

Materials and methods A cross-sectional study was conducted among women in three-degree colleges in Udupi City from March 2023 to September 2023. Ethical approval was sought from the Kasturba Hospital Ethics Committee, Kasturba Hospital, Manipal (IEC 2: 303/2022) before the commencement of the study. 2.1 Study participants and sampling One government college, one government-aided college, and one private college were selected using the lottery method. Permission from the respective Principals and University Vice-chancellor was obtained before the commencement of the study. An informed consent was obtained from the students prior to the survey. Subjects who are female, studying in degree college, belonging to the age group of 18–25 years were included in the study. Subjects who were not willing to give consent and below the age of 18 years were excluded from the study. 2.2 Sample size Assuming that 50 % of the subjects in the population are aware of third molar infection, design effect (DEFF) of 1.5, with 5 % absolute precision and 95 % confidence the sample size of 577 was obtained. This was further rounded to 600. 200 students were included in the study from each college. 2.3 Development and validation of the questionnaire Based on the subject expert inputs, a self-administered semi-structured questionnaire was designed in the English language. The questionnaire was prepared by studying the existing literature review and inputs from experts and was subjected to content validation. The pre-final version was administered to 20 college degree students for inputs on the questionnaire. Cronbach's alpha coefficient was used to check for the internal consistency of the questionnaire. The test-retest reliability was evaluated on 20 patients who filled out the second copy of the questionnaire at an interval of two weeks. The intraclass correlation coefficient was used on all the scales to analyze the reliability of ratings rated by the participants. The final draft of the questionnaire comprised of three parts, sociodemographic details, seven questions on awareness of third molar infection, and questions on oral health practice. Demographic details included age, college name, branch, and year of study. The outcomes for the items of awareness of the third molar were classified as were categorized as aware (for correct answer) and not aware (for wrong answer). Participants were explained the aim and objectives of the study in simple language and queries were solved by the investigator. Each participant took 4–6 min to fill the form. Two trained and calibrated examiners conducted the oral examinations for the students. The examination followed a standardized procedure, covering the eruption status, angulation of partially erupted and fully erupted teeth, dental caries status, pericoronitis, presence of operculum, debris, and calculus on all third molars. Participants were examined using mouth mirrors and periodontal probes while seated in a chair under natural light. The intra-examiner reliability was 0.955 and 0.949, while the inter-examiner reliability was 0.917 and 0.91. 2.4 Statistical method The statistical analysis utilized Statistical Package for Social Sciences (SPSS) Version 23, with a significance level set at p ≤ 0.05. A p-value of ≤0.05 was considered to be of statistical significance. Descriptive data of the sample population were presented as frequencies and percentages. The association between awareness of third molar infection, oral health practices, and sociodemographic details was assessed using a chi-square test. The association between mean knowledge score and age, college, branch was determined using ANOVA and Tukey's Post hoc test. The association between mean knowledge score and dental caries prevalence of dental caries and pericoronitis and history of pericoronitis was determined using independent t -test. 

Study participants and sampling One government college, one government-aided college, and one private college were selected using the lottery method. Permission from the respective Principals and University Vice-chancellor was obtained before the commencement of the study. An informed consent was obtained from the students prior to the survey. Subjects who are female, studying in degree college, belonging to the age group of 18–25 years were included in the study. Subjects who were not willing to give consent and below the age of 18 years were excluded from the study. 

Sample size Assuming that 50 % of the subjects in the population are aware of third molar infection, design effect (DEFF) of 1.5, with 5 % absolute precision and 95 % confidence the sample size of 577 was obtained. This was further rounded to 600. 200 students were included in the study from each college. 

Development and validation of the questionnaire Based on the subject expert inputs, a self-administered semi-structured questionnaire was designed in the English language. The questionnaire was prepared by studying the existing literature review and inputs from experts and was subjected to content validation. The pre-final version was administered to 20 college degree students for inputs on the questionnaire. Cronbach's alpha coefficient was used to check for the internal consistency of the questionnaire. The test-retest reliability was evaluated on 20 patients who filled out the second copy of the questionnaire at an interval of two weeks. The intraclass correlation coefficient was used on all the scales to analyze the reliability of ratings rated by the participants. The final draft of the questionnaire comprised of three parts, sociodemographic details, seven questions on awareness of third molar infection, and questions on oral health practice. Demographic details included age, college name, branch, and year of study. The outcomes for the items of awareness of the third molar were classified as were categorized as aware (for correct answer) and not aware (for wrong answer). Participants were explained the aim and objectives of the study in simple language and queries were solved by the investigator. Each participant took 4–6 min to fill the form. Two trained and calibrated examiners conducted the oral examinations for the students. The examination followed a standardized procedure, covering the eruption status, angulation of partially erupted and fully erupted teeth, dental caries status, pericoronitis, presence of operculum, debris, and calculus on all third molars. Participants were examined using mouth mirrors and periodontal probes while seated in a chair under natural light. The intra-examiner reliability was 0.955 and 0.949, while the inter-examiner reliability was 0.917 and 0.91. 

Statistical method The statistical analysis utilized Statistical Package for Social Sciences (SPSS) Version 23, with a significance level set at p ≤ 0.05. A p-value of ≤0.05 was considered to be of statistical significance. Descriptive data of the sample population were presented as frequencies and percentages. The association between awareness of third molar infection, oral health practices, and sociodemographic details was assessed using a chi-square test. The association between mean knowledge score and age, college, branch was determined using ANOVA and Tukey's Post hoc test. The association between mean knowledge score and dental caries prevalence of dental caries and pericoronitis and history of pericoronitis was determined using independent t -test. 

Results The study recruited 600 students, with an average age of 19.76 ± 1.79 years. The majority of participants were under 20 years old (77.8 %). Among them, 123(20.5 %) were Arts students (BA, MA), 147 (24.5 %) were business students (BBA, MBA), 135 (22.5 %) were commerce students ( B.com ), and 195 (32.5 %) were science students (BSc, MSc). represents the oral health practices among the students. The findings indicate that 53 % of students brush their teeth once a day, while only 19.5 % use dental floss. Additionally, 31.5 % of students have never visited a dentist. Only 17 % have taken an OPG before. The study analysis revealed 1649 (68.7 %) third molars were unerupted and 279 (11.6 %) were partially erupted third molars. 135 participants (22.5 %) had dental caries while 63 participants (10.5 %) had experienced pericoronitis. Additionally, 33 (5.5 %) students reported with a history of recurrent pericoronitis. represents the characteristics of third molar-infected teeth. The study found that the maxillary third molars were most associated with dental caries (10.4 %) and mandibular third molars had the highest frequency of pericoronitis (7.9 %). Mesioangular angulation was the most common among teeth associated with dental caries (4.3 %). There was no significant association between the position of teeth or opposing tooth in contact with the operculum and with prevalence of pericoronitis. 2.4 % of patients with pericoronitis reported of history of pericoronitis while 9.6 % of subjects reporting of history of pericoronitis did not have any signs of pericoronitis. A significant proportion of respondents in government-aided (17.8 %) and private (10.7 %) institutions acknowledged the potentially serious problems caused by third molars, whereas this awareness was lower in government institutions (5.0 %, p < 0.0001). Conversely, a notable proportion of students remained unaware about potential impact of third molars on general health, with 70.5 % from government colleges, 75.5 % from government-aided colleges, and 72.5 % from private colleges indicating lack of awareness about this aspect. A higher percentage of respondents in government institutions (28.3 %) believed that there would be no problem if the tooth does not erupt. Furthermore, the importance of visiting a dentist for symptomatic third molars was significantly recognized by respondents in government-aided (11.8 %) and private (23.7 %) institutions compared to government institutions (16.8 %, p < 0.0001). There were no significant differences in the perception of the impact of third molars on general health across branches (p = 0.397). Awareness of potential problems with third molars also varied significantly among branches, with Arts students (47.2 %) showing the highest awareness and Science students (24.6 %) showing the lowest awareness (p < 0.0001). shows the factors influencing awareness scores. ANOVA showed significant association between mean knowledge scores and branches. Post-hoc analysis using Tukey's HSD showed significantly higher scores in Arts students (3.62 ± 1.46), compared to Business (2.93 ± 1.76) and Commerce students (2.97 ± 1.36), but not significant with science students (3.34 ± 1.67). There was a significant increase in awareness of third molars with age (p = 0.001). Presence of dental caries significantly affects knowledge score, with those having dental caries having a higher score than those without (p = 0.001). Pericoronitis did not significantly affect the knowledge score (p > 0.05). However, a history of pericoronitis is associated with a significantly higher mean knowledge score (4.24 ± 1.66) compared to those without a history (p ≤ 0.001). 

Discussion Third molar infections can significantly impact student life, causing discomfort, pain, and affecting daily activities. The pain and discomfort associated with third molar infections can also disrupt sleep patterns, leading to fatigue and decreased productivity. Moreover, untreated third molar infections can worsen over time, potentially leading to more severe complications such as abscess formation, the spread of infection to surrounding tissues, and even systemic health issues if left untreated for long periods. Hence students need to be aware of the signs and symptoms of third molar infections, prioritize regular dental check-ups, and seek prompt treatment. The findings of this study shed light on several important aspects of oral health practices, third molar status, and awareness among students in various educational institutions. Firstly, the study reveals a concerning trend in oral hygiene practices among students, with only 53 % brushing their teeth once a day and a low usage of dental floss 19.5 %. This was similar to a previous study conducted among degree college students in Bengaluru This highlights a need for targeted oral health education programs to promote better oral hygiene habits among this population. The high percentage of unerupted third molars (68.7 %) and partially erupted third molars (11.6 %) is consistent with existing literature on the delayed eruption of third molars. Consequently, mandibular third molars are frequently impacted, with a range of 17 %–69 % exhibiting some level of impaction. Insufficient space for proper tooth eruption poses a risk of periodontal disease and dental caries, with this risk escalating. Such conditions significantly impact the quality of life related to oral health, necessitating heightened attention and awareness from both individuals and dentist. , The study showed that the higher prevalence of dental caries in the maxillary third molars (68.4 %) and higher prevalence of pericoronitis in the mandibular third molars (83 %) emphasize the importance of regular dental check-ups and early intervention to prevent complications associated with third molars. In the present study, it was observed that the vertical angulated third molar was most likely to cause pericoronitis. As previously observed, vertical angulated teeth are more associated with pericoronitis due to the occlusal face of the third molar, which presents grooves and fissures, in contact with the pericoronary hood. These grooves and fissures favor the accumulation of food/biofilm under the pericoronary hood, causing inflammation and resulting in pericoronitis. , , , In the present study the mean awareness score was 3.22 ± 1.60. The study highlighted variance in the mean knowledge score among different branches and colleges. This highlights the varying exposure to dental-related issues with different academic disciplines. Older students tended to have higher knowledge scores compared to younger ones. This trend suggests that as students progress through their academic journey, they accumulate more knowledge and awareness regarding oral health-related issues. Students affected by dental caries or a history of pericoronitis exhibited higher levels of knowledge compared to those without. This result may be attributed to the firsthand experience and heightened awareness or visit to a dentist that individuals with dental issues develop regarding oral health. The study also reveals gaps in awareness regarding the third molar infection and the potential problems it can cause. Conversely, a notable proportion of students remained unaware about the general health problems related to third molar infection. Untreated third molar infections can lead to the spread of bacteria from the oral cavity to other parts of the body, potentially causing systemic infections. Dental infections have the potential to enter the bloodstream systemic complications like bacteremia or sepsis, or heighten the likelihood of upper respiratory or cardiovascular ailments such as coronary artery disease and endocarditis, or potentially compromise the immune system The study observed varying beliefs about the potential impact of impacted third molars, the importance of visiting a dentist for symptomatic third molars and taking an OPG among students in different institutions. Government-degree college students showed lower awareness regarding potential problems caused by impacted third molars. Whereas, the importance of visiting a dentist for symptomatic third molars and taking an OPG was recognized among respondents in government-aided and private college students. These varying responses establish the role of varying socioeconomic status, education, and access to dental services in promoting oral health awareness and preventive care. The results of this study help us identify relevant risk factors and third molar issues to plan targeted oral health education materials and interventions. An educational institution is a platform to promote oral health awareness among students that will enable them to make well-informed decision about oral health practices and potentially identify dental issues. Oral health education should emphasize on the importance of regular dental visits and diagnostic procedures such as orthopantomogram (OPG) for early detection and management of third-molar-related complications. However, there is a potential for selection bias in this study as participants may not be representative of the entire population due to factors such as non-response bias or sampling methods. This can affect the generalizability of the study findings. Further, studies involving radiographic examinations for wisdom teeth will help to assess the number of impacted teeth, positions, shapes, and sizes of the crowns and roots, the surrounding bone, and the nerve. 

Conclusion Women in this age group have just entered into a new phase of life where they can make their own decisions. The importance of women's oral health cannot be overstated, as it directly impacts their overall well-being, academic performance, and future prospects. Promoting oral health awareness and providing access to oral healthcare services empowers women students to make informed choices about their bodies and take proactive steps towards a healthy life. This study emphasizes the importance of standardized oral health education programs tailored to the needs of students that will contribute significantly in improving oral health outcomes among young adults. Oral health education programs should address the gaps in oral hygiene practices, raise awareness about third-molar-related complications, and promote regular dental check-ups, Moreover, our findings emphasize the significance of regular dental visits and diagnostic procedures such as Orthopantomogram (OPG) for early detection and management of third-molar-related complications. 

Kasturba Hospital Ethics Committee, Kasturba Hospital, Manipal (IEC2: 303/2022). 

Data will be made available upon reasonable request to the corresponding author. 

This work was supported by the 10.13039/100018696 Indian Association of Public Health Dentistry PG Student Research Assistanceship grant. 

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 

