|Wisdom Teeth Removal Guidelines
Removal of Wisdom Teeth is one of the most common
surgical procedures performed in the UK.
There is no reliable research evidence to support a health
benefit to patients from the prophylactic removal of
pathology-free impacted third molar teeth.
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|Excerpt from the NICE Guidelines on the Extraction of
Every procedure for the removal of an impacted wisdom
tooth carries risk for the patient, including temporary or
permanent nerve damage, alveolar osteitis, infection and
hæmorrhage as well as temporary local swelling, pain and
restricted mouth opening.
There are also risks associated with the need for general
anæsthesia in some of these procedures, including rare
and unpredictable death. Such patients are therefore
being exposed to the risk of undertaking a surgical
Guidelines for the removal of Wisdom Teeth have been
developed over the years by the Royal College of
Surgeons of England and Scottish Intercollegiate
These were superseded, legally and clinically by the NICE
Guidelines. NICE states that their guidelines take
precedence over other guidelines. Unfortunately, even
though the NICE Guidelines have been extant since 2000,
Dentists, Oral Surgeons and Maxillofacial Surgeons seem
to have problems with them.
The Oral & Maxillofacial Surgeons (often consultants
looking to their private practice) will 'cherry pick' from all 3
sets of guidelines.
Some dentists refer in patients for a 'job-lot' removal of all
3rd molars (often seen with South African and Antipodean
dentists) even though the clinical need doesn’t warrant it.
Other dentists refer patients in as they have developed
lower incisor crowding. There is no evidence to show
wisdom teeth cause this crowding or that the crowding
will be relieved by the removal of the wisdom teeth
(which is presumably why in the NICE guidance, there is no
orthodontic indication for Wisdom Tooth removal).
Some surgeons demand a refinement of the Guidelines
and accept mesially-impacted lower 3rd molars as being
an indication for removal.
A major problem seems to be that the referrers have
problems with the concept of non-prophylactic removal of
Wisdom teeth cannot be prophylactically / preventively
removed (according to the NICE Guidelines). Just
because wisdom teeth are present, it does not mean they
have to be removed.
The Guidelines boil down to waiting for some pathology to develop, such as decay
in the wisdom tooth or the adjacent tooth, gum disease around the wisdom tooth,
infection around the tooth crown, cellulitis, abscess and including cyst / tumour,
tooth / teeth impeding surgery or reconstructive jaw surgery and when a tooth is
involved in or within the field of tumour resection etc.
This is regarded by some as supervised neglect.
Upper wisdom teeth and / or if the patient is having a General Anæsthetic (GA) to
remove wisdom tooth / teeth, seems to be a conundrum for some clinicians.
What is often cited is, that if the patient is having a GA, then the upper ones should
be removed as well as the lower ones.
The upper 3rd molars, once the lower ones have been removed, may do one of 3
2. Start to erupt and then ‘run out of steam’ or
3. Erupt and start to traumatise the lower mucosa.
When the latter stage has been arrived at, then I think you should consider removal
of the upper 3rd molar.
Also, there is the argument that the upper third molar is functionless and hence
should be removed. Why? Is there an indication for this in the guidelines? Is it
due to a wish to tidy things up? Often, the rationale is again for prophylactic