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Evaluation and management of asymptomatic third molars: Watchful monitoring is a low-risk alternative to extraction
Sanjivan Kandasamy Midland, Western Australia, Australia

lthough indications for the removal of symptomatic third molars are well established, a convincing case for the routine removal of unerupted asymptomatic, pathology-free third molars has not been made.1 Unlike the claims of Drs White and Proft, the evidence-based literature points toward the watchful monitoring of asymptomatic third molars when there is no pathology.1-4 Despite the various guidelines, reviews, and risks associated with these extractions, many clinicians continue to routinely remove pathology-free third molars. Until recently, this practice has been predicated on reducing the risks of mandibular incisor crowding and other complications developing in the future. From an orthodontic standpoint, third molars have essentially nothing to do with mandibular incisor crowding.5-12 Late incisor crowding is multifactorial, and factors other than third molars play important roles. The removal of third molars on the sole basis of preventing mandibular incisor crowding is unsubstantiated and unjustied. Furthermore, the low incidence (1%-2%) of complications developing from impacted third molars, such as odontogenic tumors, cysts, and mandibular angle fractures, also cannot be invoked to justify the removal of unerupted and asymptomatic third molars on the ground that at some point in the future these teeth will develop related pathology.13,14 According to Drs White and Proft, there are 3 key criteria for the extraction of asymptomatic third molars: periodontal disease, age, and informed consent. Let us discuss them individually as they relate to the evidence.
Clinical senior lecturer in orthodontics, Dental School, University of Western Australia, Nedlands, Western Australia, Australia; visiting assistant professor in orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo; private practice, Midland, Western Australia, Australia. Reprint requests to: Sanjivan Kandasamy, Department of Orthodontics, Dental School, University of Western Australia, 17, Monash Ave, Nedlands, 6009, WA, Australia; e-mail, sanj@kandasamy.com.au. Am J Orthod Dentofacial Orthop 2011;140:10-7 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2011.05.008

PERIODONTAL DISEASE

Over the past 2 decades, numerous studies have reported an association between periodontal disease and adverse pregnancy outcomes,15,16 cardiovascular disease,17 diabetes mellitus,18 various lung diseases such as pneumonia and chronic obstructive lung disease, 19 and Alzheimers disease.20 Periodontal disease is a chronic disease state, and, although the mechanism behind the association with systemic diseases is still unclear, it appears to be linked to the production of cytokines and inammatory mediators that eventually circulate systemically and possibly inuence other disease states. Due to the limitations of many of these studies, a true causal relationship has been difcult to establish and in some cases has been discredited. For example, some studies failed to show a relationship between periodontal disease and adverse pregnancies.21,22 Regardless, patients should be encouraged to improve not only their oral health, but also their overall general health, including making appropriate lifestyle changes. This will improve their quality of life (QOL) as well as reduce the possible deleterious effects of poor oral health on their general health. According to the latest results from the American Association of Oral and Maxillofacial Surgeons (AAOMS) trials and the recent AAOMS Third Molar Multidisciplinary Conference, the AAOMS published new indications for the early removal of asymptomatic third molars.23 These indications are based primarily on the assumption that third molars will most likely be a site of periodontal disease in the future that might then contribute to systemic disease. The AAOMS now recommends the routine removal of asymptomatic third molars virtually on this basis alone. However, the key question here is how does the socalled medical signicance of third molars t into the overall scheme of dentistry and orthodontics? There are many issues related to the latest AAOMS recommendations:

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The AAOMS has dened a pocket depth of 4 mm or more as pathologic disease. But is this depth really a health concern? Since some depth value must be assigned for investigative purposes, could not 3 or 5 mm easily be designated within a range of possible pathology? What about factoring the position and the unusual surrounding periodontal tissue conguration of especially the mandibular third molars? What is the biologic burden of a pocket depth of 4 mm or more in the overall general health picture? Let us put into perspective periodontal disease and its association with systemic diseases by using cardiovascular diseases, such as coronary artery disease, myocardial infarction, and strokes as examples. First, let us recall that studies to date have only shown an associational relationship between periodontal disease and cardiovascular disease. Second, in these studies, all the subjects exhibited moderate to severe periodontal disease, unlike those in the AAOMS trials. Knowing this, we can put into perspective the overplayed level of importance attached to a 4 mm pocket at a third molar in relation to the highly signicant and well-established traditional risk factors associated with cardiovascular disease such as obesity, family history, diet, age, sex, and smoking. By placing an exaggerated emphasis on the relationship between periodontal disease and systemic disease and linking this to the AAOMSs self-serving arbitrary denition of disease (pockets of 4 mm or greater), the AAOMS claims that 70% of third molars will develop signicant periodontal disease, therefore recommending the routine removal of asymptomatic third molars. This is misleading and inappropriate. Can we simply extract third molars on the basis that if and when they develop pocketing of 4 mm or greater in the future, they might indirectly initiate or inuence a plethora of systemic diseases? What about other teeth with this degree of pocketing? Do they also need to be extracted? What about options? What about each patient? What about periodontal therapy, maintenance, or monitoring? What about recommendations regarding spending time educating our patients and preventing periodontal disease with proper oral and general health advice and management? Signicant amounts of time and resources have been spent by the AAOMS producing and analyzing data to support the early routine removal of asymptomatic third molars. Little consideration has been given to other well-established guide-

lines and studies around the world that differ in their recommendations for the management of these teeth.
AGE

Age is a common factor in determining when asymptomatic third molars should be removed. The rationale is that early extractions are easier, less traumatic, and reduce the likelihood of complications. These reasons at rst seem reasonable; however, there are many other factors to also consider: Not all third molars become symptomatic or pathologic. Third molars generally improve in their angulation and position relative to the occlusal plane over time. This improvement usually occurs in the rst 3 decades of life. Many unerupted third molars that appear to be in a mesioangular position, for example, will actually straighten and erupt.24,25 Therefore, there is the potential of eruption in the fullness of time, and extracting them early when patients are in their teenage years requires a more invasive surgical extraction procedure, thereby increasing the likelihood of complications. On the other hand, many dentists and oral surgeons believe that extracting later when the roots are more developed will result in greater morbidity. A better way of assessing morbidity is rst to consider the average proportion of third molars that can cause problems, which is about a third. We then weigh the pain associated with the extraction of all problematic third molars against the usually recommended prophylactic removal of all nonproblematic or asymptomatic ones. The morbidity associated with this assessment is actually much less.26,27 Age per se is not a predisposing factor to increased complications, but, rather, with increasing age, there is an increase in health risk factors, which then inuence postoperative recovery. Risk factors include smoking, sex, oral contraceptive use, experience of the surgeon, pathology associated with the third molars before surgery, mandibular third molars vs maxillary third molars, and deeper impactions.28-33 Furthermore, the study mentioned in the Point article assessed the effects of age and sex on recovery after third molar surgery.34 The study had some limitations and unaccounted confounding variables; however, between the 2 main age groups of 15.5 to 18 and 21 to 29 years, it showed that the difference, on average, in surgery time was a few minutes greater in the older group. The surgeons actually deemed the younger group slightly more difcult.

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Recovery for all lifestyle and oral function items was found to be similar between the groups; after complex statistical analyses and manipulation, the groups were shown to be at most slightly to moderately different. Clinically, these differences were minor at best. Advocating the earlier removal of third molars on the sole basis that their future extraction will result in greater complications and morbidity is simply unfounded.
INFORMED CONSENT

The removal of unerupted, asymptomatic, pathology-free third molars is essentially an elective procedure. Because we have no way of identifying which teeth might become symptomatic in the future, informed consent is a critical issue. As a general rule, the more elective the procedure, the greater the need for adequate informed consent. Patients need to be made aware of the possible risks not only of pathology from retaining their asymptomatic third molars, but also of complications arising from their extractions. Today, patients demand more information and a better understanding before consenting to any treatment, especially for elective procedures. They need to be aware of the possibility of an overall improvement in their QOL vs the immediate and possible long-term reduction in QOL as a result of surgery and the associated complications. An improvement in QOL is most likely if patients had experienced symptoms with their third molars preoperatively than if they did not. The likelihood of legal action is greater if complications arise from surgery when the patient did not have any preoperative signs or symptoms of disease.35,36 Legal action is almost guaranteed if complications arise, and the possible risks of pathology from retaining their asymptomatic third molars were exaggerated, and if the risks of complications arise from the extractions were only touched upon or briey discussed presurgically. Based on the information we give to patients, their value of health can then be assessed: ie, what are they willing to sacrice or risk, given their preoperative symptoms, or lack of, to what they might gain in QOL postoperatively?37 Decision analysis models have shown that oral surgeons, other dental professionals, and patients perceptions of nonintervention were of greater importance than the incidence of problems from third molars.37,38 Because of the chance of pathology and the probability of extraction complications and associated disability with each complication, the

authors concluded that third molars should only be extracted if there is pathology.37,38 The key is not to dismiss the complications of extractions and the associated morbidity and underestimate their impact on the QOL of our patients. The bottom line from decision analysis is that letting sleeping dogs lie is the best risk-minimizing option, and it has a greater expected payoff for the patient. As clinicians liable for the decisions we make and the treatment recommendations we provide, we must rst put third molar periodontal disease and age into perspective and then ask ourselves these questions before accepting the AAOMSs recommendations of prophylactic extractions: What if the patient develops complications after third molar surgery? Is taking action now on the basis of what if disease develops justiable? By extracting later, if and when required, will the patient be signicantly compromised dentally? What do the other evidence-based guidelines recommend? Will I be covered legally if a complication arises? Am I willing to recommend the routine extraction of third molars, knowing how weak the justication is, and therefore take responsibility for the consequences? As a dentist or an oral surgeon, is ones recommendation for extraction primarily a practice-management decision rather than a biologic one? The key is to put into perspective the current evidence and give our patients all the information in a format that they can understand to help them make the most appropriate informed decision that best suits their needs and concerns. There are clear indications for the removal of third molars associated with symptoms and pathology as well as guidelines for when the removal of asymptomatic pathology-free third molars is justied. But the suggested strategy of routine asymptomatic third molar extraction simply fails the test of evidence-based practice, and it betrays our primary obligation as doctors to rst do no harm. As noted by Drs White and Prott, Ash et al39 recommended the early extraction of all third molars in the mid-20th century. Today, however, in the 21st century, the routine removal of asymptomatic pathology-free third molars has become a dated practice that is rapidly running out of valid excuses, and it has no justication in contemporary dentistry and medicine.

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21. Fogacci MF, Vettore MV, Thom e Le~ ao AT. The effect of periodontal therapy on preterm low birth weight: a meta-analysis. Obstet Gynecol 2011;117:153-65. 22. Newnham JP, Newnham IA, Ball CM, Wright M, Pennell CE, Swain J, et al. Treatment of periodontal disease during pregnancy: a randomized controlled trial. Obstet Gynecol 2009; 114:1239-48. 23. American Association of Oral and Maxillofacial Surgeons. Third Molar Multidisciplinary Conference; Washington, DC, October 19, 2010. Available at: http://www.aaoms.org/third_molar_ news.php. Accessed on December 15, 2010. 24. Nance PE, White RP Jr, Offenbacher S, Phillips C, Blakey GH, Haug RH. Change in third molar angulation and position in young adults and follow-up periodontal pathology. J Oral Maxillofac Surg 2006;64:424-8. 25. Sandhu S, Kaur T. Radiographic study of the positional changes and eruption of impacted molars in young adults of an Asian Indian population. J Oral Maxillofac Surg 2008;66:1617-24. 26. Friedman JW. Containing the cost of third-molar extractions: a dilemma for health insurance. Public Health Rep 1983;98: 376-84. 27. Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J Public Health 2007;97:1554-9. 28. Haug RH, Perrott DH, Gonzalez ML, Talwar RM. The American Association of Oral and Maxillofacial Surgeons age-related third molar study. J Oral Maxillofac Surg 2005;63:1106-14. 29. Baqain ZH, Karaky AA, Sawair F, Khaisat A, Duaibis R, Rajab LD. Frequency estimates and risk factors for postoperative morbidity after third molar removal: a prospective cohort study. J Oral Maxillofac Surg 2008;66:2276-83. 30. Bui CH, Seldin EB, Dodson TB. Types, frequencies and risk factors for complications after third molar removal. J Oral Maxillofac Surg 2003;61:1379-89. 31. Chuang SK, Perrott DH, Susarla SM, Dodson TB. Age as a risk factor for third molar surgery complications. J Oral Maxillofac Surg 2007;65:1685-92. 32. Chuang SK, Perrott DH, Susarla SM, Dodson TB. Risk factors for inammatory complications following third molar surgery in adults. J Oral Maxillofac Surg 2008;66:2213-8. 33. Phillips C, White RP Jr, Shugars D, Zhou X. Risk factors associated with prolonged recovery and delayed clinical healing after third molar surgery. J Oral Maxillofac Surg 2003;61:1436-48. 34. Phillips C, Gelesko S, Proft WR, White RP Jr. Recovery after third-molar surgery: the effects of age and sex. Am J Orthod Dentofacial Orthop 2010;138:700.e1-8. 35. Hupp JR. Legal implications of third molar removal. Oral Maxillofac Surg Clin North Am 2007;19:129-36. 36. McGrath C, Comfort MB, Lo ECM, Luo Y. Can third molar surgery improve quality of life? A 6-month cohort study. J Oral Maxillofac Surg 2003;61:759-63. 37. Brickley M, Kay E, Shepherd JP, Armstrong RA. Decision analysis for lower-third-molar surgery. Med Decis Making 1995;15:143-51. 38. Tulloch JFC, Antczak-Bouckoms AA. Decision analysis in the evaluation of clinical strategies for the management of mandibular third molars. J Dent Educ 1987;51:652-60. 39. Ash MM, Costich ER, Hayward JR. A study of periodontal hazards of third molars. J Periodontol 1962;33:209-19.

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