Impact of Glycemic Control on Postoperative Healing Following Impacted Mandibular Third Molar Surgery

doi:10.61336/cmejgm/26-06-99

Abstract

Introduction: To assess the effect of glycemic control on postoperative healing after impacted mandibular third molar surgery. Methods: A prospective comparative cohort study was performed in 194 patients who were undergoing extraction of impacted third molars (M3s) in the mandible. The participants were classified into good glycemic control (n=97, HbA1C<7%) and poor glycemic control (n=97, HbA1C ≥7%). ‘Independent-samples t-test, chi-square test, repeated measures ANOVA, and multivariable logistic regression’ analysis were used for data analysis. Results: Poor glycemic control was associated with significantly more postoperative pain, swelling, and trismus, and lower wound healing scores during follow-up (all p<0.001). Surgical site infection, alveolar osteitis, wound dehiscence, delayed epithelialization, and the requirement of further treatment after the surgery occurred significantly more often in patients with ‘HbA1c ≥7%’ (p<0.05). Poor glycemic control was an independent predictor of delayed wound healing (p<0.001) when analyzed using multivariable logistic regression. Conclusion: Poor glycemic control adversely affected postoperative recovery following impacted mandibular third molar surgery. Diabetic patients who are being evaluated for oral surgery should have HbA1C levels checked preoperatively and should strive to optimize their glycemic control to enhance healing and minimize postoperative complications.

Keywords

Glycemic control

HbA1c

Diabetes mellitus

Postoperative healing

Wound healing.

INTRODUCTION

The extraction of impacted mandibular third molar (IMTM) is one of the most common oral and maxillofacial surgical procedures in the world.[1] It is used commonly when there is a recurrent pericoronitis, when there is a problem with dental caries, when there is a periodontal disease of adjacent dentition, when there are cystic or tumour lesions, and for orthodontic or prosthetic indications.[2] Pain, swelling of the face, trismus, delayed soft tissue healing, alveolar osteitis, surgical site infection, and impaired wound closure are common complications that occur after the surgery and can be detrimental to the patients' quality of life and recovery.[3]

‘Diabetes mellitus (DM) is one of the fastest-growing chronic non-communicable diseases (NCD) and is a significant public health problem’.[4] Pakistan is one of the countries with the highest burden of diabetes, with more than 30% of adults being affected by diabetes, which may lead to complications for millions of people.[5] Microvascular dysfunction, impaired immune response, diminished collagen synthesis, delayed angiogenesis, heightened oxidative stress, and extended inflammatory responses are all linked to poor glycemic control, impairing wound healing and making patients prone to postoperative infections.[6]

Proper healing after oral surgery relies on a sequence of inflammatory, proliferative, and remodeling phases that depend on good vascular perfusion, immune competence, and cell regeneration.[7] Hyperglycemia has a negative impact on each of these stages by affecting neutrophil chemotaxis and phagocytosis, fibroblast proliferation, epithelialization, and collagen deposition.[8] ‘Advanced glycation end products’ (AGEs) also contribute to impaired tissue repair mechanisms via chronic inflammation and endothelial dysfunction.[9] Thus, diabetic patients, especially those who do not have good glycemic control, may experience delayed healing of the mucous membranes, longer postoperative pain, more facial swelling, dry socket, wound dehiscence, and an increased incidence of postoperative infections after undergoing oral surgery procedures.[10]

Glycated hemoglobin (HbA1c) levels are used to measure glycemic control and average glucose levels over the last two to three months and are the gold standard indicator of long-term diabetes management.[11] Patients with HbA1c less than 7% tended to have lower rates of HbA1c and improved healing, while those with higher HbA1c were consistently found to have poorer healing and higher postoperative complication rates across various surgical specialties, such as general surgery, orthopedics, vascular surgery, and implant dentistry.[12]

With the rising burden of diabetes in Pakistan and the frequency of impacted third molar surgeries in oral and maxillofacial practice, it is clinically informative to understand the effect of glycemic control on post-operative healing. The recognition of the detrimental effects of poor glycemic control on healing outcomes could enable preoperative risk stratification, optimization of blood glucose, personalized postoperative management, and minimize surgery-related complications. Secondly, locally generated evidence could be used to create evidence-based protocols specific to diabetic patients undergoing oral surgery. Therefore, this study aims to evaluate the impact of glycemic control on postoperative healing following impacted mandibular third molar surgery.

MATERIALS AND METHODS

The present study was a prospective comparative cohort study done at the Department of Oral and Maxillofacial Surgery. The study was conducted over a period from July to December, 2025 The sample size was determined with a confidence level of 95% and a study power of 80% using OpenEpi version 3.01 to compare two proportions. Based on the study by Aronovich et al., which found that delayed postoperative healing occurred in about 18% of diabetic patients after oral surgery and in 6% of people with satisfactory glycemic status, the calculation was performed.[13] With these proportions, a 95% confidence level, and an equal allocation ratio of 1:1, the minimum number of participants required was determined to be 194, including 97 patients in each group. This sample size was deemed sufficient to identify a significant difference between postoperative healing in the good and poor glycemic control groups. A consecutive non-probability sampling method was used. The study included patients from 18 to 60 years of age who were diagnosed with impacted third molars in the lower jaw that needed to be taken out. Patients diagnosed with ‘type 2 diabetes’ mellitus and who had ‘HbA1c’ documented in the previous four weeks were eligible. Those who gave written informed consent and agreed to follow-up visits at all appointments were recruited. The following patients were excluded: those with uncontrolled systemic conditions other than diabetes mellitus, immunocompromised conditions, malignancy, pregnancy or lactation, chronic corticosteroid or immunosuppressive medications, bleeding disorders, previous radiotherapy treatment of the head and neck, acute odontogenic infections that required urgent treatment, smokers with more than 10 cigarettes/day, alcohol or substance abuse, and medication history known to affect wound healing. Patients who did not undergo the postoperative follow-up or had a clinical record that was incomplete were also omitted from the study. Ethical approval was obtained from the ‘Institutional Research and Ethics Committee’ of the respective institution before the commencement of the study. All participants gave informed written consent to participate. Demographic parameters such as age, gender, Body Mass Index, diabetes duration, comorbidities, and current antidiabetes drugs were collected with a data collection form on a structured basis. The level of glycemic control was evaluated through ‘glycated hemoglobin’ (HbA1c) levels taken within four weeks before surgery. Patients were divided into two groups by their HbA1c levels, ‘Group A (HbA1c <7.0%)’ and ‘Group B (HbA1c ≥7.0%)’.[13] The clinical and radiographic evaluation of all the affected mandibular third molars was done with the aid of orthopantomograms. The ‘Pederson Difficulty Index’ was used to assess surgical difficulty.[14] Local anaesthetic was used for all surgical procedures, which were performed in a standard manner by consultant oral and maxillofacial surgeons, whereby the mucoperiosteal flap was reflected, when necessary, the bone gutter was created, and the teeth were sectioned; all teeth were then washed, and primary closure was carried out using 3-0 silk sutures. The time of surgery has been observed from the time of the incision to the final step of wound closure. Antibiotics, non-steroidal anti-inflammatory drugs, and chlorhexidine mouthwash, according to departmental protocol, were given to all patients postoperatively. The third, seventh, and fourteenth postoperative days were the days when the participants were reviewed. A 10-cm Visual Analogue Scale (VAS) was used to evaluate pain intensity.[15] Standardized linear facial measurements were used to assess facial swelling between predetermined landmarks. The inter-incisal distance was used to assess the extent of trismus, with the maximum mouth opening recorded. The ‘Landry Wound Healing Index’ was used to evaluate wound healing.[16] The surgical site infection, alveolar osteitis, wound dehiscence, delayed epithelialization, and the need for further treatment were recorded at every follow-up visit in the postoperative period by the same examiner to reduce inter-examiner variability. IBM Statistical Package for ‘Social Sciences (SPSS) version’ 26.0 was used to enter and analyze data. Continuous data ‘(age, HbA1c level, duration of surgery, pain score, facial swelling, mouth opening, and wound healing scores)’ were presented as mean SD. Categorical variables that were presented as frequencies and percentages were gender, duration of diabetes, and type of impaction, surgical site infection, alveolar osteitis, wound dehiscence, and delayed healing. The normality of continuous variables was determined by the ‘Shapiro–Wilk test’. Normally distributed continuous variables were analyzed using an independent sample t-test. The ‘Chi-square test and Fisher's exact’ test were used to compare categorical variables between the two study groups. Repeated measures analysis of variance was used to assess changes in pain, swelling, trismus, and wound healing over the postsurgical follow-up period. Multivariate logistic regression was used to assess the association between poor glycemic control and delayed wound healing and postoperative complications after adjusting for age, sex, body mass index, surgical difficulty, surgical duration, and duration of diabetes. Throughout the analysis, a p-value < 0.05 was deemed statistically significant.

RESULTS

This study has 194 patients, of whom 97 patients are in good glycemic control and 97 patients are in poor glycemic control. There were no differences between the two groups in terms of age, gender distribution, BMI, hypertension, or antidiabetic therapy type (p>0.05). However, patients with poor glycemic control had a significantly longer duration of diabetes and higher HbA1c levels than those with good glycemic control (p<0.05). (Table 1).

The characteristics of impacted mandibular third molars and operative variables were similar between the two groups. There were no statistically significant differences in the pattern of impaction, Pederson Difficulty Index scores, or duration of surgery, suggesting similar surgical difficulty between the study subjects (p>0.05). (Table 2).

Patients who had poor glycemic control had significantly more postoperative pain at all follow-up times than patients with good glycemic control. There was a gradual decrease over time in both groups, and repeated measures analysis showed there was a significant improvement over time (p<0.001). (Table 3).

Patients with poor glycemic control had the highest facial swelling at every assessment point, while maximum mouth opening was the lowest at every assessment point. All parameters improved over time in both groups, and the changes were significant for all parameters for repeated measures (p<0.001). (Table 4).

The wound healing scores on the Landry Wound Healing Index showed that patients with good glycemic control had statistically higher scores on days 3, 7, and 14 after surgery. The healing process continued to improve with repeated visits in both groups, but patients with poor glycemic control consistently had slower improvement (p<0.001). (Table 5).

Poor glycemic control was associated with postoperative complications. Surgical site infection, alveolar osteitis, wound dehiscence, delayed epithelialization, and the need for additional postoperative treatment were all significantly higher in this group compared with patients who had good glycemic control (p<0.05). (Table 6).

After adjusting for potential confounding variables, poor glycemic control (HbA1c ≥7%) remained an independent predictor of delayed wound healing by multivariable logistic regression analysis. In addition, the duration of diabetes and the Pederson Difficulty Index were independently associated with delayed healing, while sex, age, and body mass index did not show any significant association. (Table 7).

Table 1. Baseline demographic and clinical characteristics of study participants (n = 194)

Variable	Good Glycemic Control ‘(HbA1c <7%)’ (n=97)	Poor Glycemic Control ‘(HbA1c ≥7%)’ (n=97)	p-value
Age (years)	39.8 ± 9.2	41.3 ± 8.7	0.241
Male	49 (50.5)	53 (54.6)	0.567
Female	48 (49.5)	44 (45.4)
BMI (kg/m²)	27.2 ± 3.8	28.0 ± 4.1	0.164
Duration of diabetes (years)	6.1 ± 2.7	7.2 ± 3.4	0.018*
HbA1c (%)	6.4 ± 0.4	8.6 ± 1.0	<0.001*
Hypertension	24 (24.7)	31 (32.0)	0.262
Oral hypoglycemic agents	70 (72.2)	58 (59.8)	0.069
Insulin therapy	27 (27.8)	39 (40.2)	0.066
*Significant at p<0.05.

Table 2. Characteristics of impacted mandibular third molars and operative variables

Variable	Good Control (n=97)	Poor Control (n=97)	p-value
Mesioangular impaction	41 (42.3)	39 (40.2)	0.928
Vertical impaction	26 (26.8)	28 (28.9)
Horizontal impaction	20 (20.6)	19 (19.6)
Distoangular impaction	10 (10.3)	11 (11.3)
Pederson Difficulty Index	6.5 ± 1.4	6.8 ± 1.6	0.172
Duration of surgery (minutes)	28.9 ± 7.4	30.4 ± 8.2	0.181

Table 3. Comparison of postoperative pain (VAS score)

Follow-up	Good Control	Poor Control	p-value
Day 3	5.2 ± 1.3	6.4 ± 1.5	<0.001*
Day 7	2.7 ± 1.0	3.8 ± 1.2	<0.001*
Day 14	0.8 ± 0.7	1.5 ± 0.8	<0.001*
Repeated measures ANOVA			<0.001*

Table 4. Comparison of postoperative facial swelling and mouth opening

Variable	Good Control	Poor Control	p-value
Facial swelling (cm)
Day 3	3.4 ± 0.8	4.2 ± 0.9	<0.001*
Day 7	1.8 ± 0.6	2.5 ± 0.7	<0.001*
Day 14	0.5 ± 0.3	0.9 ± 0.5	<0.001*
Maximum mouth opening (mm)
Day 3	28.8 ± 4.6	24.9 ± 4.4	<0.001*
Day 7	37.6 ± 3.8	34.0 ± 4.0	<0.001*
Day 14	42.8 ± 3.1	39.7 ± 3.6	<0.001*
Repeated measures ANOVA			<0.001*

Table 5. Comparison of wound healing (Landry Wound Healing Index)

Follow-up	Good Control	Poor Control	p-value
Day 3	2.8 ± 0.6	2.3 ± 0.6	<0.001*
Day 7	4.0 ± 0.7	3.2 ± 0.8	<0.001*
Day 14	4.8 ± 0.4	4.1 ± 0.6	<0.001*
Repeated measures ANOVA			<0.001*

Table 6. Postoperative complications

Variable	Good Control (n=97)	Poor Control (n=97)	p-value
Surgical site infection	3 (3.1%)	12 (12.4%)	0.015*
Alveolar osteitis	4 (4.1%)	13 (13.4%)	0.021*
Wound dehiscence	2 (2.1%)	10 (10.3%)	0.017*
Delayed epithelialization	7 (7.2%)	24 (24.7%)	0.001*
Additional postoperative treatment	5 (5.2%)	18 (18.6%)	0.004*

Table 7. Multivariable logistic regression analysis for predictors of delayed wound healing

Variable	Adjusted OR	95% CI	p-value
HbA1c ≥7%	3.94	1.86–8.35	<0.001*
Age (per year increase)	1.02	0.98–1.05	0.326
Male sex	1.11	0.58–2.14	0.744
BMI	1.06	0.98–1.16	0.142
Duration of diabetes	1.09	1.00–1.19	0.046*
Pederson Difficulty Index	1.28	1.02–1.60	0.031*
Duration of surgery	1.04	1.01–1.08	0.019*
*Statistically significant (p<0.05).

DISCUSSION

The results of the present study indicated that there was a significant correlation between poor glycemic control and greater postoperative pain, facial swelling, trismus, delayed wound healing, and increased incidence of postoperative complications associated with impacted third molar surgery in the mandible. In addition, an HbA1c level of ‘≥7%’ was still an independent risk factor for delayed healing after controlling for potential confounding factors. These results highlight the need for proper glycemic management before elective oral surgical procedures and provide evidence that hyperglycemia negatively affects postoperative recovery via impaired inflammatory regulation, decreased collagen formation, delayed angiogenesis, and impaired immune function.

The present findings corroborate with a prospective observational study by Krishnan et al. (2021) that found that patients with type 2 diabetes with poor glycemic control had a greater risk for developing postoperative infectious complications and delayed healing after dental extractions, albeit the association was not statistically significant. The authors concluded that attention should be paid to glucose monitoring in the perioperative stage, even for routine dentoalveolar surgery.[17] This stronger correlation that was noted in the current study could be attributed to the increased surgical trauma required for the removal of an impacted third molar in the mandible versus simple extraction.

In the present study, the significantly greater degree of postoperative pain among patients with poor glycemic control is consistent with recent findings showing that delayed tissue repair and prolonged inflammation exacerbate postoperative discomfort. The relationship between wound repair and the patient's postoperative symptoms was demonstrated by a randomized clinical trial published by Izzetti et al. (2026) that compared interventions aimed at early postoperative wound healing with those not targeting it, revealing that the latter group had higher postoperative pain and reduced soft tissue healing.[18]

Likewise, the marked facial edema and decreased mouth opening seen in poorly controlled diabetic patients are biologically plausible, as the more serious hyperglycemia increases the release of inflammatory cytokines and slows down tissue resolution. These findings are corroborated by the recent meta-analysis, which showed that pain, swelling, and trismus were the major signs of postoperative recovery following third molar extraction and highlighted that delayed wound healing may be associated with the presence of these symptoms.[19]

In the present study, patients with ‘HbA1c ≥7%’ had significantly lower Landry wound healing scores, suggesting the slowness of soft tissue repair throughout the postoperative period. The results of this study are corroborated by Izzetti et al. (2026), who concluded that better wound healing procedures resulted in better early mucosal healing following third molar surgery. In both studies, their intervention was not on glycaemic control, but it drew focus to the fact that optimizing the biological healing pathways can significantly enhance the postoperative recovery process.[18]

The significantly higher rates of surgical site infection, alveolar osteitis, wound dehiscence, delayed epithelialization, and postoperative treatment with antibiotics in poorly controlled diabetes are in line with the available evidence. In a meta-analysis published in 2023, it was found that improving postoperative wound management was a key factor in reducing adverse outcomes of oral surgery, particularly wound-healing complications, highlighting the importance of local tissue healing in postsurgical outcomes.[20]

Our results are consistent with the systematic reviews, which showed that effective control of inflammation and optimization of wound healing are the two main factors contributing to a good outcome following a mandibular third molar extraction. The review also emphasized that the patient-related factors that may interfere with the healing process should be considered more in depth when assessing patients preoperatively, thus corroborating the clinical relevance of glycemic optimization that was proven in the present study.[21]

Clinically, recent studies have also shown that treatment aimed at promoting local wound healing can aid in recovery, regardless of the technique used. Golubenko et al. (2026) demonstrated that postoperative pain and wound healing after third molar surgery with the dressing were similar to wound healing with antibiotic treatment, highlighting the importance of maintaining an optimal healing environment for better clinical outcomes.[22]

A more recent study by Gao et al. (2026) showed that the use of the modified flap transfer and suturing techniques was effective in improving wound healing and decreasing postoperative complications after impacted M3 extraction. Both investigations are primarily concerned with surgical technique and not with metabolic control, but they point to the importance of minimizing influences that hinder tissue regeneration for optimal healing.[23]

The results of the present study are corroborated by evidence from nutrition research. A prospective study published in 2026 that studied the postoperative complications following wisdom tooth extraction showed that predisposing biological risk factors were the main determinants of wound-healing complications and dietary intake was not. This is indirect support for the present results as it indicates that glycemic control as a systemic host factor has a more significant effect on postoperative healing than a dietary factor.[24]

Finally, the present multivariable regression analysis showed that ‘HbA1c ≥7%’ remained an independent predictor of delayed wound healing after controlling for surgical difficulty, the duration of surgery, BMI, age, and duration of diabetes. This discovery reinforces the emerging evidence that glycemic control, by itself and not diabetes alone, has a significant impact on postoperative recovery. The findings thus endorse the need to routinely evaluate ‘HbA1c levels’ in diabetic patients before surgery for impacted mandibular third molar extraction. Glycemic control must be optimized before surgery, as this can help to lower postoperative morbidity, facilitate rapid wound healing and enhance patient outcomes.

Limitations

There are some limitations of this study. First, it was performed at a single tertiary care center, which limits the findings to be generalizable to other populations and healthcare settings. Second, the follow-up period was short (14 days) and long-term healing results and late complications were not assessed. Third, glycemic control during the preoperative period was evaluated by a single HbA1C level only and the fluctuation in blood glucose levels around the time of surgery was not monitored. In addition, potentially confounding factors like nutritional status, oral hygiene habits and socioeconomic factors were not evaluated and may have affected wound healing. Despite the constraints of these limitations, the prospective design, uniform surgical protocol, postoperative management and detailed evaluation of healing outcome increase the validity of the study results.

CONCLUSION

Poor glycemic control was significantly related to higher postoperative pain scores, trismus, facial swelling, delayed wound healing, and incidence of postoperative complications in impacted third molar surgery. The patients with ‘HbA1c ≥7%’ had slower recovery and were more likely to have complications with their healing than the other patients with good glycemic control. In addition, the poor glycemic control was an independent predictor of delayed wound healing even after adjusting for possible confounding factors. The results suggest that strict glycemic control assessment and optimization prior to elective impacted 3rd molar extraction is crucial. Periodic ‘HbA1c’ testing can help identify high-risk candidates, help manage perioperative care, and reduce postoperative complications.

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