Third Molars

Prevalence of Caries & Periodontal Disease in Retained Third Molars

Jodi Metcalfe
Victoria Janes
Carly McGregor
EVBP 5500
DUE DATE: July 29th, 2016
Instructor: Carrie Maynard

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Introduction
Wisdom teeth extraction can often be seen as a rite of passage, or a milestone in
the process of aging. Many patients often ask the question Why do I really need to have
my wisdom teeth pulled? Statistics demonstrate that third molar extraction is a highly
common oral surgical procedure with approximately five million individuals undergoing
this procedure in the United States each year (Guilherme da Costa, et al, 2013). Complete
and concrete reasoning for extraction is seldom thoroughly explained to patients,
however indications for third molar extraction include high incidence of pericoronitis,
periodontitis, bone resorption, caries in third molars and the distal of second molars, oral
pathologies such as cysts and tumors, and crowding of mandibular incisors (Guilherme
da Costa, et al, 2013). There is an apparent divide among dental professionals in the
stance on third molar extraction and whether it is truly necessary based on the risks
associated with retaining them. Throughout this research paper we will examine the
effects of retained wisdom teeth and their influence on periodontal disease and caries.
Will the retaining of third molars result in an increased risk of developing dental caries
and periodontal disease?
Discrepancy & Debate in the Dental Field
Third molar extraction remains a great debate in the dental field, and it varies
depending on location and the practitioner. It is evident throughout research studies,
expert opinion papers, and advice from professionals; that the existence of periodontal
disease, presence of cysts, tumours or abscesses, a person's age, and level of oral hygiene
are determining factors for removal (Rafetto, 2015). Due to the position and malposition
of third molars there are many considerations that must be taken when determining if or

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when third molars will be extracted (Rafetto, 2015). Prior to any procedure, it is critical
that a proper evaluation is completed. Assessing not only the clinical health of the
growing or present wisdom teeth but also the health of the neighboring teeth and other
vital structures should be taken into consideration (Rafetto, 2015).
Distinctly, articles are disagreeing about the suggestion of surgical extraction of
impacted third molars (Boughner, 2016). There is a common understanding throughout
these articles, even when opposed to the removal of third molars. Specifically disagreeing
with eliminating wisdom teeth is the American Public Health Association, stating that it is
recommended to leave impacted third molars in place unless they create or become
associated with a pathological condition (Boughner, 2016). Some may find that their
wisdom teeth cause no pain allowing them to assume they will not be a problem (Sharma,
2010). Found within the Journal of the Canadian Dental Association it is stated: that
even asymptomatic impacted third molars may become associated with periodontal
disease and caries (Boughner, 2016). Boughner 2016 references the American
Association of Oral and Maxillofacial Surgeons (AAMOS) and states:
Online information on wisdom teeth may confuse the issue by stating that third
molars which have erupted into the mouth in a normal, upright position may be as
prone to disease as those third molars that remain impacted. That is, all third
molars are inherently prone to disease and are therefore reasonable candidates for
extraction (p. 1).
It is evident that third molar extraction is conducted for preventive purposes in
regards to caries, periodontal disease and other pathologies. The risk of future

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complications and ramifications related to retained third molars is a strong indication

towards eventual extraction.
Dental Caries in the Third Molar Region
Despite the variation in opinion in the dental field regarding extraction of third
molars; there is evidence to support their removal in relation to reducing the patients
incidence and risk of caries in the third molar region. A systematic review of articles
regarding indications for third molar extractions stated, Dental caries may be present
because of the patients difficulty in reaching the region to clean it adequately (Steed,
2014, p. 571). This statement was made after reviewing other articles which provided
evidence regarding the increase in the incidence of caries in the third molar region both
on the erupted/partially erupted third molars as well as on the second molars. Increased
risk of caries remains a prominent indication for third molar extraction to be
recommended to patients by dental professionals. This systematic review concluded that
caries accounts for 15 percent of third-molar extractions (Steed, 2014, p. 571). This
meaning that because fifteen percent of individuals with retained third molars have caries
in this region; extraction of these teeth will eliminate their risk for caries of the third
molars, and reduce the risk of caries on the second molars (Steed, 2014). Studies have
been conducted in regards to third molars increasing the incidence of distal cervical
caries in second molars. Distal cervical caries of the second molars are more common
when the third molar is angulated mesial (McArdle, McDonald, & Jones, 2014). A study
of 100 individuals whose third molars were extracted due to distal cervical caries of the
second molar concluded that The prophylactic removal of a partially erupted
mesioangular third molar will prevent distal cervical caries forming in the second molar

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tooth (McArdle, McDonald, & Jones, 2014). It is evident that as a preventive measure
and therapeutic measure for caries treatment, third molar extraction has a prominent role.
Dental caries on third molars must be viewed as an imperative indicator for third
molar extraction, not only for the health of the tooth; also for the health of the patient.
Caries in the third molar region if not treated in a timely manner may result in eventual
pupal invasion or necrosis, thus requiring a root canal or emergency extraction which
could have been prevented by prophylactic extraction (Steed, 2014, p. 571). Untreated
caries in third molars that spread to the pulp of the tooth may result in localized or
spreading fascial space infection (Steed, 2014, p. 571). This meaning that severe caries
in third molars may cause further infection in the form of an abscess either localized to
the tooth or spread further in the fascial region.
Pericoronitis & Periodontal Disease in the Third Molar Region
Risk of periodontal disease is also a widely indicated reason for dental
professionals to recommend third molar extraction to their patients. Third molar eruption
and impaction can cause inflammation and pain in the third molar region (Steed, 2014).
The presence of periodontal disease is determined by dental professionals such as dentists
and dental hygienists through clinical observation, periodontal probing depth
measurements, bleeding indexes, and radiographic evidence. Periocoronitis is commonly
seen surrounding erupting teeth, specifically third molars. According to Steeds 2014
study Pericoronitis is a mild to moderate inflammatory response of soft tissues
surrounding a partially erupted tooth, and 25 to 30 percent of impacted third molars are
extracted because of acute or recurrent pericoronitis. (p. 571). This inflammation can
often cause pain and discomfort of the patient, therefore leading to eventual extraction of

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the partially erupted tooth. In a study of individuals with retained third molars, increased
biochemical mediators associated with inflammation were found, related to the
inflammation clinically observable in the third molar region (Steed, 2014).
Despite evidence of periodontal disease as determined by a dental professional,
many third molars remain asymptomatic. A study of 329 individuals with asymptomatic
third molars was conducted to examine the periodontal probing depth measurements in
the third molar region (Steed, 2014). The third molar region is referring to the probing
depths on all surfaces of the third molars as well as on the distal of the second molars
(Steed, 2014). It was found that 82 participants, or 25% had at least one probing depth of
5mm or greater in the third molar region (Steed, 2014). Additionally, it was found that of
this 25%, 98% had an attachment loss of at least 2mm in the third molar region (Steed,
2014). This study indicates that a large portion of individuals with retained third molars
have active periodontal disease in this region. The study was conducted on asymptomatic
third molars, meaning that the individuals are experiencing no pain or symptoms
associated with their third molars. Steed 2014 argues, The term asymptomatic is an
insufficient description of the clinical status of the third molar. Just as in many other
disease courses, such as diabetes and cardiovascular disease, the absence of symptoms in
a third molar does not always reflect true absence of disease. (p. 570). This evidence
substantiates the importance of extracting third molars as a preventive and therapeutic
intervention in terms of periodontal disease.
Conclusion
In summary, third molar extraction remains a great debate in the dental industry.
However, there is substantial evidence based research to support the extraction of third

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molars as both a preventive and therapeutic intervention for disease and or pathologies.
This paper served to critically examine literature regarding indications for third molar
extraction, specifically studies investigating the incidence of caries and periodontal
disease. The evidence concludes that caries and periodontal disease are evidence based
research reasons to extract third molars whether they are fully or partially erupted,
symptomatic or asymptomatic. Dental professionals need to utilize their evidence
informed decision making skills and encompass the scientific evidence, their own
expertise and knowledge, as well as the clients needs and preferences, when making the
decision of whether or not to recommend to a client to have their third molars extracted.

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8
References

Boughner, J. (2016). Maintaining Perspective on Third Molar Extraction. Journal of the

Canadian Dental Association, 79.
Costa, M., Pazzini, C., Pantuzo, M., Jorge, M., & Marques, L. (2013). Is there justification for
prophylactic extraction of third molars? A systematic review. Brazilian Oral Research ,
183-188.
McArdle, L., McDonald, F., & Jones, J. (2014). Distal cervical caries in the mandibular second
molar: an indication for the prophylactic removal of third molar teeth? Update. British
Journal of Oral and Maxillofacial Surgery, 185-189.
Rafetto, K. (2015). Managing Impacted Third Molars. Department of Oral & Maxillofacial
Surgery & Hospital Dentistry, 364-371.
Steed, M. (2014). The indications for third-molar extractions. Journal American Dental
Association, 570-573.