Thames Valley Priorities Committees

Buckinghamshire/Milton Keynes Priorities Committee Policy Statement: Removal and Referral of Impacted Third Molars Policy No:
ref TV

7 November 2005

Date of Issue:

There is no reliable research evidence to support a health benefit to patients from the prophylactic removal of pathology-free impacted wisdom teeth.1 Consequently the National Institute of Clinical Excellence (NICE) has recommended that the practice of prophylactic removal of pathology free impacted third molars should be discontinued. 2 The aim of these guidelines is to reduce inappropriate referrals and help other patients receive their treatment more rapidly. Symptom free third molars which have a functional role in the dentition or which are deeply impacted should not be removed, but should be regularly monitored for signs of pathology. Removing asymptomatic third molars may lead to both major and minor complications. 3, 4, 5, 6,
7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19

Little controversy surrounds the removal of impacted third molars when they cause pathological changes and/or severe symptoms such as infection, non-restorable carious lesions, cysts, tumours, and destruction of adjacent teeth and bone.

Referral for surgical removal of impacted third molars may be necessary where palliative treatment is not appropriate, is ineffective, or where there is evidence of pathology such as: Unrestorable caries 4 Repeated episodes of pericoronitis Non-treatable pulpal and or periapical pathology20,21 Serious infection such cellulitis and osteomyelitis Internal/external resorption of the tooth or adjacent teeth22 Diseases of the follicle such as cysts/ tumour23 Where the tooth is impeding surgical procedures such as osteotomy, tumour resection or trauma management24,25 Fracture of tooth Periodontal disease of second molar due to third molar impaction26 Plaque formation while being a risk factor for pericoronitis or caries is not in itself an indication for surgery. This statement will be reviewed in the light of new evidence or further guidance by NICE.

References:
1

The effectiveness and cost-effectiveness of the prophylactic removal of wisdom teeth. Fujian Song, Susan O'Meara, Paul Wilson, Jos Kleijnen, Susan Golder. NHS Centre for Reviews and Dissemination, University of York, November 1999. 2 NICE Technology Appraisal Guidance No. 1. Guidance on the removal of Wisdom teeth. March 2000
3

Song F, Landes DP, Glenny AM, Sheldon TA. Prophylactic removal of impacted third molars: an assessment of published reviews. 1996;NHS Centre for Reviews and Dissemination, University of York. 4 Von Wowern N, Neilson HO. The fate of impacted lower third molars after the age of 20. A four-year clinical follow up. Int J Oral Maxillofac Surg. 1989; 18: 277-80. 5 Venta I, Turtola L, Ylipaavalniemi P. Change in clinical status of third molars in adults during 12 years of observation. J Oral Maxillofac Surg. 1999; 57: 386-9. 6 Garcia RI, Chauncey HH. The eruption of third molars in adults: a 10 year longitudinal study. Oral Surg Oral Med Oral Pathol. 1989; 68: 9-13. 7 Robinson PD. The impacted wisdom tooth: to remove or to leave alone? Dental Update. 1994; 21: 245-8. 8 Peterson LJ. Rationale for removing impacted teeth: when to extract or not to extract. J Am Dent Assoc. 1992; 123:198-204. 9 Parameters of care for Oral and Maxillofacial surgery: a guide for practice, monitoring and evaluation 1995; (AAOMS Parameters of Care -95) 3 Oral and Maxillofacial Surg 53 supp. 10 NHS Centre for Reviews and Dissemination, University of York. Prophylactic removal of impacted third molars: is it justified? Effectiveness Matters. 1998; 3: 2. 11 Goldberg M, Nemerich AN, Marco WP. Complications after third molar surgery: a retrospective study. Int J Oral Surg. 1985; 14:29-40. 12 Hugoson A, Kugelberg CF. The prevalence of third molars in a Swedish population. An epidemiological study. Community Dent Health. 1988; 5: 121-38 13 Brickley M, Shepherd J, Mancini G. Comparison of clinical treatment decisions with US National Institutes of Health consensus indications for lower third molar removal. Br Dent J. 1993; 175: 1025. 14 Blackburn CW, Bramley PA. Lingual nerve damage associated with the removal of lower third molars. Br Dent J. 1989; 167:103-7. 15 Mercier P, Precious D. Risks and benefits of removal of impacted third molars. A critical review of the literature. lnt J Oral Maxillofac Surg. 1992; 21: 1 7-27. 16 Carmichael FA, McGowan DA. Incidence of nerve damage following third molar removal: a West of Scotland Oral Surgery Research Group study. Br J Oral Maxillofac Surg 1992; 30: 78-82. 17 Royal College of Surgeons of England Faculty of Dental Surgery. The management of patients with third molar teeth: report of a working party convened by the Faculty of Dental Surgery. 1997; The Royal College of Surgeons of England Faculty of Dental Surgery. London. 18 British Association of Oral & Maxillofacial Surgeons. Clinical guidelines. London, January 1995 www.baoms.org.uk 19 Shepherd JP, Brickley M. Surgical removal of third molars. BMJ. 1994; 309: 620-1 20 Leone SA, Edenfield MJ, Cohen ME. Correlation of acute pericoronitis and the position of the mandibular third molar. Oral Surg. 1986; 62; 245-50. 21 Piironen J, Ylipaavainiemi P. Local predisposing factors and clinical symptoms in pericoronitis. Proc Finn Dent Sc. 1981; 77:278-82. 22 Nitzan D, Keren T, MarmaryY. Does an impacted tooth cause root resorption of the adjacent one? Oral Surg 0ral Med Oral Pathol. 1981; 51; 221-4. 23 Knights EM, Braklaw WC, Kesslar HP. The incidence of dentigerous cysts associated with a random sampling of unerupted third molars. General Dentistry. 1991: 39: 96-8. 24 Williams JL. Fractures of the facial skeleton. 1994. Churchill Livingstone, Edinburgh. 25 Rubin MM, Koll Tj, Sadoff RS. Morbidity associated with incompletely erupted third molars in the line of mandibular fractures. J Oral Maxillofac Surg. 1990; 48: 1045-7. 26 Kugelburg CF, Ahlestrom U, Ericson S, Hugoson A, Kvint S. Periodontal healing after lower molar surgery in adolescents and adults. A prospective study. Int J maxillofacial Surg. 1991;20:18-24