Article
Nearly 4 years ago, I co-authored a paper with my colleague Naeem Adam1 entitled ‘NICE guidance … time for a rethink?’ This paper alluded to the misplaced therapeutic advice from NICE (TA1) in 2000, that partially erupted lower third molars that were apparently disease free, should not be removed.
This guidance was based upon the fact that there was no reliable research to suggest that the removal of asymptomatic wisdom teeth benefits the patient. While this statement about the ‘evidence’ is undoubtedly true, it is almost certainly also true for a large percentage of the medical and dental procedures that are carried out on a daily basis. This is a reflection upon the level of research evidence to which we all, of course, aspire rather than the value of the clinical procedures performed. Sadly, so many Cochrane reviews conclude ‘there is insufficient evidence to determine …’ meanwhile clinical practice continues unabated. It is vital to understand that lack of evidence of an effect is exactly that … a lack of evidence, not as many people mistakenly conclude, a lack of effect.
For the past decade and a half, many of us, who review our cases long term, could merely sit by and watch in frustration as patient after patient with partially erupted wisdom teeth had surgical removal denied on the back of this ‘lack of scientific evidence’. Originally NICE commented that they would review the guidance in 2003, but this was never done.
It always seemed so screamingly obvious to many, that leaving a patient in late teenage or early 20s with mesially impacted, partially erupted, wisdom teeth is leaving them vulnerable to infection, periodontal problems and caries in the second and/or third molars. Also, removing the offending wisdom teeth early, in a fit healthy late teenager, has to be more desirable than operating some 10 or 20 years later.
At long last, a document ‘Parameters of care for patients undergoing mandibular third molar surgery’2 has been published by the Faculty of Dental Surgery, which reviews the guidelines. Evidence has now suggested increasing patient harm due to these wisdom teeth not being removed. It is not a formal systematic review, rather a consensus view from the ‘great and good’ in a variety of related disciplines, of the best available evidence.
They refer to the Finish study3 confirming that by 38 years of age, most lower third molars require removal. Another study followed 118 subjects with third molars over 18 years and found 64% required removal. Finnish guidelines recommend an interventional approach to avoid the risks of surgery in older patients.
The Faculty of Dental Surgery now accepts that there is increasing evidence that ignoring asymptomatic third molars is not in the patient's best interest because it delays inevitable surgery, with additional damage to mandibular second molars. Up to 78% of retained third molars are eventually extracted due to infection, periodontal disease or caries in second or third molars.
I think the review is timely, and hopefully many patients will now benefit from this more ‘patient-centred’ approach. The report emphasizes that patient involvement is paramount and, once the pros and cons of tooth removal have been explained to the patients, their opinion will be considered along with the clinician's experience and judgement when deciding the fate of the third molars.