| Exodontia.Info |
| Wisdom Teeth Removal Guidelines |
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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.
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 procedure
unnecessarily.
Guidelines for the removal of Wisdom Teeth have been
developed over the years by the Royal College of Surgeons
of England and Scottish Intercollegiate Guidelines Network.
These were superseded, legally and clinically by the NICE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 pick and mix from the 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
3rd molars.
Wisdom teeth cannot be prophylactically / preventively
removed. 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 – decay in the wisdom tooth or the adjacent tooth,
gum disease around the wisdom tooth, infection around
the tooth crown, cellulitis, abscess and osteomyelitis,
internal / external resorption of the tooth or adjacent teeth,
fracture of tooth, disease of follicle 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 the patient is having a general
anæsthetic 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 general
anæsthetic, then the upper ones should be removed as well
as the lower ones.
The upper third molars, once the lower ones have been
removed, may do one of 3 things:
1. Nothing
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 third 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
reasons.
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.
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 procedure
unnecessarily.
Guidelines for the removal of Wisdom Teeth have been
developed over the years by the Royal College of Surgeons
of England and Scottish Intercollegiate Guidelines Network.
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 pick and mix from the 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
3rd molars.
Wisdom teeth cannot be prophylactically / preventively
removed. 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 – decay in the wisdom tooth or the adjacent tooth,
gum disease around the wisdom tooth, infection around
the tooth crown, cellulitis, abscess and osteomyelitis,
internal / external resorption of the tooth or adjacent teeth,
fracture of tooth, disease of follicle 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 the patient is having a general
anæsthetic 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 general
anæsthetic, then the upper ones should be removed as well
as the lower ones.
The upper third molars, once the lower ones have been
removed, may do one of 3 things:
1. Nothing
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 third 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
reasons.
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