Gustatory function after third molar extraction

David M. Shafer, DMD,a Marion E. Frank, PhD,b Janneane F. Gent, PhD,c and Mark E. Fischer,
DMD,d Farmington, Conn
UNIVERSITY OF CONNECTICUT AND CONNECTICUT CHEMOSENSORY CLINICAL RESEARCH CENTER

Objective. The purpose of this study was to determine the severity and time course of taste changes after extraction of all 4
third molars.
Study design. Taste function in 17 patients was measured before third molar surgery and at 1 month and 6 months after
surgery. Two tests were administered: a whole-mouth, above-threshold test in which subjects sipped, expectorated, and then
rated the intensities and identified the taste qualities of various solutions, and a localized test in which subjects rated and iden-
tified solutions painted with cotton swabs on different oral sites.
Results. Intensity ratings for solutions in the whole-mouth test were reduced by approximately 14% for NaCl, citric acid, and
quinine hydrochloride at 1 month after surgery and had not recovered by 6 months after surgery for citric acid (P < .02). The
taste quality of NaCl was identified correctly less frequently after third molar extraction. Perceived taste intensity on discrete
areas of the tongue was significantly reduced after surgery (P < .05). Patients with the most severely impacted molars gave the
lowest taste intensity ratings to whole-mouth test solutions at 6 months after surgery (P < .02). In contrast, taste function in a
group of subjects who received only local dental anesthesia was not affected.
Conclusions. Gustatory deficits occur after third molar extraction, persist for as long as 6 months after surgery, and appear to
be associated with depth of impaction.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:419-28)

The extraction of third molar teeth is one of the most
common surgical procedures performed in this country.
In 1977, it was estimated that 2.25 million third molars
are removed annually.1 One of the most common and
accepted risks associated with third molar extraction
(TME) is damage to peripheral sensory branches of the
trigeminal nerve, primarily the inferior alveolar and
lingual nerves. The location of the lingual nerve, which
lies in the soft tissue in close proximity to mandibular
third molars, puts the nerve at particular risk of damage
during an extraction.2-5 In addition to the lingual nerve,
the greater and lesser palatine nerves may be at risk of
damage during maxillary TME.6-8 All these nerves are
peripheral general somatosensory branches of the
trigeminal nerve.
Taste chemoreception is also transmitted via some of
This study was supported in part by research grant #5P50-DC00168
to M.E.F. from the National Institute on Deafness and Other
Communication Disorders, National Institutes of Health, Bethesda,
Md.
aAssociate Professor and Acting Chair, Department of Oral and
Maxillofacial Surgery, School of Dental Medicine.
bProfessor, Department of Biostructure and Function, School of
Dental Medicine; Program Project Director, Connecticut
Chemosensory Clinical Research Center.
cResearch Associate, Taste and Smell Center, Connecticut
Chemosensory Clinical Research Center.
dGraduate Student, Department of Orthodontics, School of Dental
Medicine.
Received for publication Aug 13, 1998; returned for revision Oct 7,
1998; accepted for publication Nov 12, 1998.
Copyright © 1999 by Mosby, Inc.
1079-2104/99/$8.00 + 0 7/12/95977
these same nerves, putting taste as well as somatosen-
sory function potentially at risk with TME.9 Taste
information from the anterior tongue is carried via the
chorda tympani (CT) branch of the facial nerve, which
joins the lingual branch of the mandibular nerve after
the latter has passed through the foramen ovale. The
CT-lingual nerve travels toward the lateral border of
the floor of the oral cavity and lies against the medial
surface of the mandible in the area of the third molar.
It is at this point that it is most susceptible to damage
during surgical procedures. Damage may be related to
variation in TME surgical technique10 or to anatomic
variation of the CT-lingual nerve.3 Taste sensation of
the soft palate is carried by fibers of the seventh cranial
nerve that reach the lesser palatine nerve through the
greater superficial petrosal nerve. The lesser palatine
nerve, which exits the foramina at the level of the third
molars, can be damaged during maxillary TME during
actual removal of the tooth, especially if the tooth is
placed more palatally.
Nerves may also be injured when local anesthesia is
being administered, either as a result of direct contact
with the needle or as a result of adverse neurotoxic
effects of the anesthetic compound.7,11 A report of 2
cases documents taste dysfunction after injections of
local anesthesia without surgery.12 However, in a retro-
spective analysis of paresthesias after injections of
local anesthesia without surgery that were reported to
the Ontario Professional Liability Program from 1973
to 1993, it was estimated that the incidence of taste
dysfunction was extremely small (1:785,000).13 A

419
420 Shafer et al
recent study by Kraft and Reinhard14 demonstrated a
0.15% incidence of lingual sensory disturbance in
12,104 patients receiving mandibular block anesthesia
(the type of anesthesia administered to participants in
the present study) for routine dental procedures
without associated surgery. Sved et al15 estimated the
incidence of neural damage to be as high as 1% for
injections of the maxillary nerve via the greater pala-
tine canal (a type of injection not performed in the
present study) for 101 injections.
Peripheral nerve damage associated with TMEs is
reported almost exclusively as somatosensory change
(primarily involving touch), as inferred from patient
reports of paresthesia.16-21 The overall prevalence of
injury to the trigeminal nerve branches from TME has
been estimated to be between 0.06% and 11.5%,8 with
most of these cases resolving within 6 months of the
time of injury.22 For example, Mason23 studied general
sensory lingual nerve function (alterations in light
touch, pain, and 2-point discrimination) after TME and
found an 11.5% incidence of paresthesia within 1
month of TME that declined to 0.6% at 6 months post-
operatively. Although involvement of taste sensation
has been inferred from these reports,24 none of the
studies that have been mentioned specifically evaluated
taste function.
Gustatory alterations after extractions have been
reported in a case study,25 in a survey on quality of life
after TME,21 and in studies of oral and maxillofacial
surgery patients.26,27 Zuniga et al27 examined taste
function in patients with known surgical nerve injuries
postoperatively; taste funciton was evaluated sepa-
rately for the 2 sides of the anterior tongue.28 Partial
and complete transections of the lingual nerve occur-
ring during odontectomy (10 of 12 patients) resulted in
gustatory deficits on the side of injury.27 However, no
preextraction taste-testing was performed.
The purpose of the present study was to prospectively
determine the incidence, severity, and time course of
suprathreshold taste changes after extraction of the 4
third molars through the use of stimulation of both the
whole mouth and restricted oral sites.
MATERIAL AND METHODS
Subjects
Patients. Seventeen patients (11 women and 6 men)
aged 15 to 28 years (mean ± standard deviation, 21.2 ±
3.7 years) participated in the study. These subjects
were recruited from among patients who came to the
Department of Oral and Maxillofacial Surgery for
extraction of all 4 third molar teeth.
Presurgery panoramic radiographs were used by one
of us (D.M.S.) to determine the degree of impaction on
the basis of the Pell and Gregory29 classification
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1999
scheme. Each of the 2 maxillary third molars was
assigned a depth-of-impaction score, a score of 1 repre-
senting no or minimal vertical impaction, a score of 2
representing moderate impaction, and a score of 3
representing deep impaction. Each of the 2 mandibular
third molars was assigned 2 scores, a “width score” and
a “depth score.” The width score represented the hori-
zontal distance between the second molar and the ante-
rior border of the ascending ramus, a score of 1 repre-
senting a space greater than the width of the third
molar, a score of 3 representing a space less than the
width of the third molar, and a score of 2 representing
all or most of the third molar within the ramus. The
depth score represented the depth of impaction, the
scoring being identical to that for the maxillary molars.
An overall impaction score for all 4 third molars was
calculated as the sum of the classification scores of the
2 maxillary molars plus a weighted sum of the 2
mandibular scores (1⁄3 [width score × depth score]). The
theoretical range of the overall impaction score is 2.67
to 12. Weighting approximately equalizes the contribu-
tion of each tooth to the overall score. Table I lists the
classification scores and the overall impaction scores
for each subject.
Comparison group. Twenty dental students (8
women and 12 men) aged 24 to 36 years (mean ± stan-
dard deviation, 25.8 ± 2.9 years) served as a comparison
group with respect to possible effects of local anesthesia
and/or effects of repeated taste-testing. These subjects,
recruited from among second-year dental students at the
University of Connecticut Health Center, were given
the tests of taste function before and 1 month and 6
months after participating in a Dental School training
session on the administration of local anesthesia.
Psychophysical methods
Each participant was given a symptom questionnaire
and underwent psychophysical testing that included 2
tests of taste function that were administered during the
month preceding the dental procedure (either surgery
or dental anesthesia without subsequent surgery) and
then 1 month and 6 months after the procedure. A 1-
month delay between surgery and the first postopera-
tive testing was selected to allow for resolution of peri-
operative edema and/or inflammation.30 A 6-month
follow-up was used because it has been reported previ-
ously that most postoperative CT-lingual nerve pares-
thesias resolve by 6 months after surgery.23 All
psychophysical testing was performed by M.E.F. or
staff members of the Connecticut Chemosensory
Clinical Research Center (CCCRC) who were not
involved in the surgical procedures.
Symptom questionnaire. Through use of a ques-
tionnaire administered in interviews, self-assessments
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Shafer et al 421
Volume 87, Number 4

Table I. Pell and Gregory29 classification of each third molar for all study subjects (N = 17)
Maxillary third molar Mandibular third molar
Right Left Left Right Impaction severity
Age (y) Gender Depth score (a) Width (b) Depth (a) Width (b) Depth overall score
20 M 1 1 1 1 1 1 2.67
25 M 1 1 1 1 1 1 2.67
23 F 1 1 2 1 2 1 3.33
24 F 1 1 2 1 2 1 3.33
25 F 1 2 1 1 2 2 4.67
19 F 2 2 1 1 2 1 5.00
25 M 3 1 2 1 2 1 5.33
19 F 2 2 2 2 2 1 6.00
17 M 2 2 2 2 2 2 6.67
24 F 2 2 2 2 2 2 6.67
21 F 2 2 2 2 2 2 6.67
19 F 2 3 2 1 2 2 7.00
20 F 3 3 2 2 2 2 8.67
18 F 3 3 2 2 2 2 8.67
28 M 3 3 3 1 3 2 9.00
15 M 3 3 2 3 2 3 10.00
16 F 3 3 2 3 2 3 10.00
M, Male; F, female.

of taste and somatosensory function were obtained for
16 of the 17 TME patients and for all subjects in the
comparison group. Data from one patient’s question-
naire were incomplete and therefore were excluded
from analyses related to self-reported symptoms. At
all 3 test visits, subjects were asked to describe their
taste sensitivity as normal, less acute than it used to
be, or more acute than it used to be. For the 2 post-
procedure visits, subjects were asked to note any
temporary loss of taste, any localized loss of taste,
and whether any particular taste quality was affected.
Each subject was also asked to report any intraoral
numbness that occurred immediately after the proce-
dure or that continued to be present at either of the
follow-up visits.
Whole-mouth taste test. Each of the participants
(TME patients and subjects in the comparison group)
was given a whole-mouth, above-threshold test of taste
function. This test, developed and used by the
CCCRC,31 uses the psychophysical technique of
magnitude matching of stimuli for 2 senses (tasting and
hearing) to assess a subject’s relative ability to taste. In
this technique, the subject is instructed in the use of
magnitude estimation to rate the intensity of each test
stimulus, either a solution or a tone. Five concentration
levels (in 1⁄2 log steps) of NaCl (0.01-1.0 mol/L),
sucrose (0.01-1 mol/L), citric acid (0.32 mmol/L-
0.032 mol/L), and quinine hydrochloride (0.01
mmol/L-1.0 mmol/L) are presented in 5-mL samples,
which are sipped and then expectorated. The subject is
asked to identify the quality (salty, sour, sweet, bitter,
or tasteless) and intensity of each test solution and also
to rate the loudness of several decibel levels (38-98 dB)
of a 1000-Hz tone. The tones are presented through
calibrated headphones to better control the sound level
presented to the subject. Under the assumption that the
subjects have normal hearing and, in this case, that
hearing is unaffected by TME, intensity ratings given
to the test solutions are normalized to the loudness
ratings given to the tones. Normalized ratings are used
to calculate psychophysical functions for each
compound (NaCl, sucrose, citric acid, and quinine
hydrochloride). The use of loudness as a sensory yard-
stick permits comparisons of perceived taste intensity
both between subjects and within subjects across
time.31
Spatial taste test. Each TME patient and each
subject in the comparison group was also given a test
of localized taste function.32 This test consists of iden-
tifying the quality of each test stimulus and rating the
stimulus on an intensity scale from 0 (no taste) to 9
(very strong taste). In each trial, the strongest concen-
tration of one of the 4 compounds used in the whole-
mouth taste test was painted with a cotton swab on one
of 6 locations in the mouth—the left and right anterior
and posterior-lateral surfaces of the tongue (within the
receptive field of the CT-lingual nerve) and the 2 sides
of the soft palate, lateral to midline (within the recep-
tive field of the palatine nerve). For the TME patients
in this study, taste function at all locations tested was
considered to be at risk from TME because of the close
physical proximity of the extraction site to the periph-
eral nerve conducting afferent chemosensory informa-
tion from the area.
422 Shafer et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1999

Table II. ANOVA (main effects and first-order interac- Local anesthesia with 2% lidocaine with epinephrine
tions) results for taste intensity ratings from whole- 1:100,000 was used for all the extractions; typically,
mouth test for TME patients (N = 17) and subjects in the quantity used was 1.8 mL for each tooth extracted.
comparison group (N = 20) Standard injection techniques were used. An inferior
Within-subject effects alveolar nerve block was used for the extraction of all
df (v1, v2) F P mandibular molars. A greater palatine nerve block and
either a posterior superior alveolar nerve block or local
TME patients
Time 2, 32 3.63 .038 buccal infiltration were used to provide anesthesia for
Compound 3, 48 10.47 .0001 all maxillary extractions. All patients received intra-
Concentration 4, 64 301.07 .0001 venous sedation with midazolam hydrochloride and
Time × compound 6, 96 2.29 .042 fentanyl citrate.
Time × concentration 8, 128 1.13 ns
The subjects in the comparison group received injec-
Compound × concentration 12, 192 2.07 .021
Comparison group tions in at least 2 third molar areas, including one
Time 2, 38 2.16 ns maxillary area (greater palatine and posterior superior
Compound 3, 57 13.69 .0001 alveolar nerve blocks) and one mandibular area (infe-
Concentration 4, 76 301.28 .0001 rior alveolar nerve block). Each of 13 subjects received
Time × compound 6, 114 1.4 ns
2 injections, each of 6 subjects received injections in 3
Time × concentration 8, 152 1.16 ns
Compound × concentration 12, 228 6.95 .0001 areas, and 1 subject received injections in all 4 third-
molar areas.

For the subjects in the comparison group, an area was
considered “at risk” if it was innervated by the nerve
that had received the local anesthesia injection—ie, the
palatal area on the side of the injection was “at risk”
after greater palatine and posteror superior alveolar
nerve blocks, and the anterior and posterior-lateral
tongue areas on the side of the injection were “at risk”
after inferior alveolar nerve blocks.
Surgery and anesthesia
In cases of impacted mandibular third molars, the
extractions were performed through use of a standard
buccal mucoperiosteal flap approach. Alveolar bone
was removed, and the teeth were sectioned when
necessary by means of a surgical rotary handpiece
through use of the buccal approach. Neither a chisel
nor a lingual approach was used for the extraction of
any mandibular teeth. For impacted maxillary third
molars, a buccal approach was used as well. Overlying
alveolar bone was removed through use of hand instru-
mentation. No maxillary tooth was sectioned. Erupted
maxillary teeth (9 of 34 molars in this study; depth
score = 1; Table I) and erupted mandibular teeth (16 of
34 molars) were removed nonsurgically through use of
the elevator and forceps technique. When necessary for
the sake of avoiding the application of excessive force,
mandibular teeth with depth scores of 1 were sectioned
through use of rotary instrumentation. All extraction
sites were closed with simple interrupted chromic
sutures when necessary. All extractions were
performed by faculty members or residents in the
Department of Oral and Maxillofacial Surgery.
Data analysis
Whole-mouth taste test. Postoperative intensity judg-
ments were compared with preoperative intensity judg-
ments. Analyses of variance (ANOVAs) were applied to
the data from each subject group to examine the effects
of (1) time, (before, 1 month after, and 6 months after
the procedure), (2) compound (NaCl, sucrose, citric
acid, quinine hydrochloride), and (3) stimulus concen-
tration on perceived whole-mouth intensity. Of partic-
ular interest in these analyses were the main effect of
time, the effect of time by compound, and the effect of
time-by-concentration interactions.
The effect of degree of impaction on the postsurgery
taste intensity rating, expressed as a proportion of the
presurgery rating, was examined through use of 1-way
ANOVAs. For these analyses, each patient was classi-
fied as belonging to one of 3 impaction severity
groups; those in group 1 (“low”) had impaction scores
of at least 2.67 (the minimum score) but no greater than
4.00 (one third of the maximum score of 12—ie, all 4
molars erupted), those in group 2 (“medium”) had
scores greater than 4.0 but no greater than 8.0 (two
thirds of the maximum score), and those in group 3
(“high”) had scores greater than 8.0.
Quality judgments for each solution presented in the
whole-mouth test were coded as follows: “correct” (a
response of “salty” for NaCl, “sweet” for sucrose,
“sour” for citric acid, and “bitter” for quinine
hydrochloride), “incorrect” (an incorrect quality name
response for the solution), or “tasteless” (an intensity
rating of 0). For each compound, we then calculated
the proportions of correct, incorrect, and tasteless
quality judgments for the 10 presentations of that
compound within each test session (5 different concen-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 87, Number 4
Table III. Mean total taste intensity ratings from whole-mouth test (summed across concentrations) and ANOVA
results for TME patients (N = 17)
Total taste score (mean + SE)
Pre Post 1
NaCl 114.41 ± 6.61 90.59 ± 4.82
Citric Acid 137.62 ± 10.68 116.57 ± 6.61
Quinine hydrochloride 119.81 ± 10.01 98.33 ± 8.47
Sucrose 91.53 ± 7.12 82.43 ± 6.54
*Significant.
trations, each sampled twice). Quality judgments
(correct, incorrect, or tasteless) were compared preop-
eratively and postoperatively for the TME patients and
before and after anesthesia for the subjects in the
comparison group through use of 2-way ANOVAs to
examine the effects of time and compound.
Spatial taste test. Preprocedure and postprecedure
intensity ratings were compared. For the TME patients,
a 4-way ANOVA was used to examine the effects of
time, compound (NaCl, sucrose, citric acid, quinine
hydrochloride), stimulus location (anterior, posterior-
lateral, soft palate), and side (left, right) on perceived
taste intensity. For the subjects in the comparison
group, only data from areas considered to be “at risk”
were used in the analyses.
Because all areas in the spatial test were considered
to be at risk for the TME patients, the proportion of
correct, incorrect, and tasteless quality judgments for
this test were based on 12 stimulus presentations (one
concentration of each of 4 compounds presented twice
to each of 6 oral locations). For each subject in the
comparison group, the proportion was based on the
number of areas considered to be “at risk” for that
subject. Preprocedure (surgery or anesthesia alone) and
postprocedure quality judgments in the spatial test for
each group were compared through use of 1-way
ANOVAs to examine the effect of time.
RESULTS
Symptom questionnaire
No participants reported taste or oral somatosensory
problems before surgery (TME patients) or before their
local anesthesia injections (subjects in the comparison
group). One TME patient reported a temporary taste loss
and temporary numbness on the anterior tongue imme-
diately after surgery. No TME patients or subjects in the
comparison group reported experiencing taste loss or
oral numbness at 1 month or 6 months after procedure.
Whole-mouth taste function
Perceived taste intensity decreased significantly after
surgery for the TME patients, as seen in a significant
Shafer et al 423
Within-subject effects
Time Time × concentration
Post 6 F P F P
102.04 ± 8.24 4.46 .02* 1.00 .44
108.44 ± 8.24 5.24 .01* 1.66 .12
100.62 ± 8.45 2.46 .10 1.86 .07
84.59 ± 8.14 0.74 .49 0.78 .62
effect of time, and remained unchanged for the subjects
in the comparison group (Table II). Compound,
concentration, and compound-by-concentration inter-
action were significant factors unrelated to the dental
procedure (time) for both groups. For each subject
group, intensity judgments for sucrose were signifi-
cantly lower than intensity judgments for the other
compounds (P < .009). The significant compound-by-
concentration interaction was due to the consistently
steeper increase in intensity ratings by each subject
group for the 2 midrange NaCl concentrations (0.1 mol
and 0.3 mol/L; Fig 1, A).
The time-by-compound interaction for the TME
patients suggests that intensity judgments for the
different compounds were unequally affected by
surgery; thus, the results for each compound were
analyzed separately. In comparison with presurgery
measurements, the perceived intensities collapsed across
concentrations (“total taste score”) were significantly
lower at 1 month after surgery for NaCl (P < .004),
quinine hydrochloride (P < .04), and citric acid (P < .01)
and remained significantly lower at 6 months after
surgery for citric acid (P < .02; Table III; Fig 1, A, B, and
C). Perceived intensity of sucrose was not significantly
affected by TME (Fig 1, D). As would be expected,
concentration was a significant factor for the perceived
intensity for all 4 compounds (P < .0001); more concen-
trated solutions had greater perceived intensities.
To further examine the effect of surgery on each of the
4 test compounds, we used the “total taste score” for
each compound (the sum of intensity ratings across
concentration). When total taste intensity is expressed as
a proportion of presurgery intensity for each subject, the
mean proportion is significantly lower than 1.0 for NaCl
at 1 month after TME (0.83 ± 0.06; t = 3.10, P < .003)
and for citric acid at 1 month (0.88 ± 0.05; t = 2.41, P <
.01) and 6 months (0.83 ± 0.07; t = 2.44, P < .01) after
TME. When the proportions are averaged across
compounds, the mean proportion at 1 month after TME
is also significantly lower than 1.0 (0.88 ± 0.05; t = 2.31,
P < .02), whereas the mean proportion at 6 months after
TME is not (0.92 ± 0.07; t = 1.10, P < .14).
424 Shafer et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1999

Fig 1. Mean whole-mouth intensity ratings by subjects (N = 17) for test solutions (in molar concentration
plotted on log scale) of (a) NaCl, (b) citric acid, (c) quinine hydrochloride, and (d) sucrose before (Pre), 1
month after (Post-1), and 6 months after (Post-6) TME. Significant effects of time are indicated for NaCl
(single asterisk; P < .02) and citric acid (double asterisk; P < .01).

To estimate the “incidence” of taste deficits after
TME, we used the data on proportion of total taste
intensity reduction in the following way: We calculated
a 99% confidence interval around 1.0 using the average
standard error for the average proportions for the 4
taste compounds at 1 month and 6 months (standard
error = 0.063). We then counted the number of average
taste intensity proportions less than 0.837, the lower
limit of the 99% confidence interval. At 1 month after
TME, 9 (53%) of 17 patients had mean proportions less
than 0.837, and at 6 months, 6 of these proportions had
not recovered. In addition, 3 cases whose proportional
responses were within the 99% confidence interval at 1
month were below the lower limit at 6 months; thus,
the “incidence” at 1 and 6 months was the same.
For the TME surgery patients, time did not have a
significant effect on the number of correct quality iden-
tifications (77% ± 2%, on average) in the whole-mouth
test. However, the P value (< .07) for the time-by-
compound interaction suggested that some of the
compounds may have been affected by time. In fact,
there were significantly fewer correct responses to NaCl
at 1 month after surgery (69% ± 5%) than before surgery
(81% ± 3%; Fig 2). NaCl was primarily misidentified as
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 87, Number 4
Fig 2. Percentage of correct taste quality identifications made
by TME patients (N = 17) in whole-mouth taste test.
Significant difference from presurgery identifications of NaCl
is indicated (asterisk; P < .002).
sour or bitter (84% of all misidentifications) at 1 month
after surgery, and the decrease in correct identifications
occurred exclusively at the 3 lowest concentrations. For
the subjects in the comparison group, neither time nor
time-by-compound interaction was significant for the
number of correct identifications.
For the TME patients, neither time nor time-by-
compound interaction was a factor affecting the
number of incorrect or tasteless responses. Results
were similar for the subjects in the comparison group,
except that the time-by-compound interaction was
significant for incorrect responses (P < .03): there were
significantly fewer incorrect responses to citric acid at
6 months after anesthesia (4% ± 2%) than at 1 month
after anesthesia (13% ± 3%; P < .002). This could
reflect improvement with practice.
Spatial taste function
In general, for the TME patients, perceived intensity
of solutions restricted to small regions of the tongue
was significantly reduced after TME (time F[2,32] =
3.22, P < .05). Neither location nor compound was a
signifcant factor affecting perceived intensity.
Perceived intensity averaged over all stimulus sites and
compounds was significantly reduced at 1 month after
TME (from 5.0 ± 0.4 to 4.6 ± 0.4 on a scale of 0 to 9;
P < .04) and remained significantly reduced at 6
months after TME (4.5 ± 0.4; P < .03; Fig 3).
Analysis of intensity data from the “at risk” areas of
the subjects in the comparison group revealed a signif-
icant effect of compound (F[3,57] = 5.12, P < .003) but
no significant effect of time and no significant time-by-
compound interaction. Averaged over time and “at
risk” areas, these subjects consistently judged quinine
hydrochloride to be weakest and NaCl to be strongest
in intensity.
Quality identification of solutions in the spatial test
Shafer et al 425
Fig 3. Mean taste intensity ratings given to each compound
summed over 6 oral locations in spatial taste test. Significant
differences from presurgery intensities are indicated (asterisk;
P <.05).
by TME patients and by subjects in the comparison
group were unaffected by time. The TME patients
identified an average of 86% ± 3% of the solutions
correctly and 8% ± 2% incorrectly; they found 6% ±
2% to be tasteless. The subjects in the comparison
group identified (on the “at-risk” areas only) 90% ± 3%
correctly and 3% ± 2% incorrectly; they found 7% ±
2% to be tasteless.
Severity of impaction
On the basis of depth-of-impaction score, each
patient was classified into one of 3 severity-of-
impaction groups—“low” (N = 4), “medium” (N = 8),
or “high” (N = 5). At 1 month after TME, the total taste
intensity of solutions in the whole-mouth taste test was
significantly reduced to an average of 88% of
presurgery values for all 3 impaction groups (Fig 4). At
6 months after TME, however, the impaction groups
were significantly different (F[2,14] = 4.16, P < .04;
Fig 4): average taste intensity for patients in the group
with the highest severity-of-impaction scores was
reduced to 65% of presurgery values and was signifi-
cantly lower than values for patients in the other 2
impaction severity groups (Student-Newman-Keuls
post-hoc comparison, P < .05; Fig 4).
DISCUSSION
Taste and general sensory information are carried by
nerves that may be injured during surgery within the oral
cavity. Although neural injuries may infrequently follow
TME, significant effects on somatosensory function have
been documented; for the most part, however, effects on
gustatory function have only been inferred.24,33
Our finding of taste deficits after TME is consistent
with a recent study by Zuniga et al,27 in which
complete or partial transection of the lingual nerve was
confirmed during microsurgery to repair neural
426 Shafer et al
Fig 4. Mean whole-mouth total taste intensity ratings of all 4
test compounds expressed as proportions of presurgery inten-
sities at 1 month and 6 months. Mean proportions are shown
for subjects grouped by severity of molar impaction scores
(low [n = 4], medium [n = 8], and high [n = 5]) and for all
subjects (All Pts; N = 17). Significant differences from
presurgery intensities are indicated (asterisk; P < .02).
damage resulting from TME.27 Gustatory function,
tested before and up to 12 months after lingual nerve
repair, was found to improve substantially in some
patients after microsurgery.27
However, before the present study, the effects of
TME on gustatory function had not been prospectively
evaluated. Our results demonstrate that TME, and not
the associated use of local anesthetic, has an impact on
gustatory function. The primary effect of TME was on
taste intensity, and this was consistent across all taste
qualities. The significant decrease in correct identifica-
tion of NaCl at 1 month after surgery was exclusively
at low concentrations.
Reductions in perceived intensity were measured
across all test solutions for many of the subjects in our
sample, and although our subjects did not report loss of
taste, the estimated incidence of taste loss was 53%.
Blackburn and Bramley34 reported an 11% incidence of
lingual nerve somatosensory dysfunction after TME;
however, this estimate was based on the number of
patients reporting any alteration in tongue sensation at
the time of suture removal after surgery (123 of 1117
patients). It is not directly comparable to our estimate
for taste loss, which is based on sensory measurements
that were made before and after surgery and would thus
be more likely to identify postoperative changes. In the
Blackburn and Bramley34 study, somatosensory testing
was performed only postoperatively and only on those
patients who reported changes; the investigators
observed that by 6 weeks after surgery, more than one
half of these patients had recovered and that by 9
months after surgery only 1.6% of those in the original
group (18 of 1117 patients) continued to have problems.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1999
We estimate that in our patients the incidence of taste
loss at 6 months after surgery continued to be 53%.
A differential effect of TME on somatosensory and
gustatory function might be expected because of the
microscopic architecture of the lingual nerve. For
example, the CT-lingual nerve carries fibers of both the
fifth cranial nerve (somatosensory) and the CT branch
of the seventh cranial nerve (taste). A study by
Watanabe et al35 demonstrated a very specific topo-
graphic organization of the CT fibers within the human
lingual nerve. The CT fibers maintained a superficial
and posterolateral distribution within the lingual nerve;
therefore, damage to a specific part of a nerve (as in a
partial transection or pressure on one side of the nerve)
could differentially affect taste and touch. If, as
suggested by Watanabe et al,35 the CT fibers are
primarily located laterally, damage to the lateral side of
the nerve may affect taste more than an injury to the
medial aspect.
In addition to spatial organization, nerve fiber myeli-
nation and/or size may play a role in differential
sensory effects in lingual nerve injury. A study by
Holland and Robinson36 on cat CT-lingual nerves
demonstrated that the proportion of myelinated and
nonyelinated CT and trigeminal fibers within the
lingual nerve is similar. However, the myelinated CT
fibers had a smaller mean circumference than the
myelinated trigeminal fibers. In compression injuries,
fibers that are smaller in diameter and fibers that are
peripherally located are affected to a greater extent
than larger myelinated and central fibers.37 Therefore,
a compression injury to the CT-lingual nerve could
result in a greater effect on taste than on fine-touch
sensory components.38 Furthermore, one third of the
precrush number of CT myelinated fibers remained at
4 months after CT-nerve crush in hamsters.39 Such a
loss in nerve fibers may contribute to the incomplete
recovery of function at 6 months after TME, especially
as is seen in patients with severe impaction.
Clinical evidence for differential effects of lingual
nerve injury is also provided by the study by Zuniga et
al.27 After surgical repair of lingual nerve injuries, only
5 (50%) of 10 patients demonstrated recovery of taste
function at 1 year after surgery. On the other hand, at 1
year after surgical repair, 9 (90%) of 10 of the patients
demonstrated an increase in somatosensory function.
The significant decrease in spatial taste perception in
all areas tested at 1 month and 6 months after TME is
anatomically consistent with our expectations that all
areas were at risk and is also consistent with the whole-
mouth test results. These same areas are at risk from
the injection of local anesthetic solution used during
the extraction. Nerve injury solely from the injection of
local anesthesia in the region of an extracted third
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 87, Number 4
molar is possible,12 but overall incidence of paresthesia
has been reported to be less than 1%.13-15 Results from
the subjects in our comparison group, who had local
anaesthesia administered without subsequent TME,
show no significant change in spatial taste perception
from the “at risk” areas. Thus, anesthesic injection is
not likely to be a significant factor in our TME
patients’ results. Rather, our spatial data suggest that
the decreased taste perception observed in the patients
is anatomically related to the tooth extraction and not
to the injection of local anesthesia.
The relationship between whole-mouth taste intensity
ratings, depth of impaction, and the passage of time
further supports the contention that it was the actual
tooth extraction and not the injection of the local anes-
thesia that resulted in decreased taste perception. The
amount and method of local anesthesia administration
did not differ for the various depths of impaction. The
taste loss observed at 1 month was not related to depth
of impaction and may have been due to temporary
factors, such as nerve compression secondary to edema.
However, there were differences in the extraction tech-
nique directly related to severity and depth of impaction,
which in turn may have resulted in longer-lasting nerve
damage. This possibility is supported by the fact that
after 6 months, the 5 patients with the most deeply
impacted teeth showed the most severe taste loss.
In conclusion, we have demonstrated gustatory
deficits after the extraction of all 4 third molars. The
deficits, which may be the result of nerve compression
(possibly secondary to edema), stretch, or laceration, do
not result in patient complaints, but they persist for at
least 6 months. It is possible that the taste loss persists
beyond 6 months and, together with other factors that
affect taste and accumulate over a lifetime, contributes
to the decrease in taste function seen with age.40,41
We thank A. Mott (Department of Medicine, University of
Connecticut School of Medicine), M. Banki and D. Miller
(University of Connecticut School of Dental Medicine), and
C. Sampson and B. Formaker (Connecticut Chemosensory
Clinical Research Center) for assistance during various
phases of this work. This study includes data collected by
M. E. Fischer for his Master of Dental Science thesis.
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Reprint requests:
Marion E. Frank, PhD
Department of Biostructure and Function
MC 3705
University of Connecticut
School of Dental Medicine
Farmington, CT 06030-3705

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