Guidance on the Extraction of Wisdom Teeth

Evidence-based recommendations on removing wisdom teeth in adults.

# Guidance
The practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS.
The standard routine programme of dental care by dental practitioners and/or paraprofessional staff, need be no different, in general, for pathology free impacted third molars (those requiring no additional investigations or procedures).
Surgical removal of impacted third molars should be limited to patients with evidence of pathology. Such pathology includes unrestorable caries, non-treatable pulpal and/or periapical pathology, 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.
Specific attention is drawn to plaque formation and pericoronitis. Plaque formation is a risk factor but is not in itself an indication for surgery. The degree to which the severity or recurrence rate of pericoronitis should influence the decision for surgical removal of a third molar remains unclear. The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery.# Clinical Need and Practice
Permanent molar teeth normally erupt from the age of six onwards, with the third molars (wisdom teeth) being the last to erupt, usually between the ages of eighteen and twenty four years. Wisdom teeth may erupt normally into correct dental alignment and function or conversely develop in non- or minimally functional positions. Impaction occurs when there is prevention of complete eruption due to lack of space, obstruction or development in an abnormal position. This may result in a tooth erupting partially or not at all. Wisdom teeth can also be impacted, either erupting partially or not at all. Impaction may be associated with pathological changes including pericoronitis, an increased risk of caries and periodontal disease in adjacent teeth, and orthodontic problems in later life.
Removal of wisdom teeth is one of the most common surgical procedures performed in the UK. Current practice includes both the removal of impacted third molars causing pathological changes as well as the early prophylactic removal of pathology-free impacted third molars. Wide variations in the rates of this latter procedure across the country, which suggest that in the past, up to 44% of wisdom teeth removals and prophylactic surgery may have been inappropriate, have been reported. However, in recent years, changes in the practice of removal of wisdom teeth may have taken place in response to Faculty of Dental Surgery, Royal College of Surgeon's guidelines. Even so, some 22% of procedures may still be inappropriate. In 1994/95 there were approximately 36,000 inpatient and 60,000 day case admissions in England. More recent figures (1998/99) for Wales indicate that there were up to 3000 procedures. It is estimated that the total cost to the NHS in England and Wales of wisdom teeth extractions is up to 12 million per year.
        Current clinical practice and parameters of care: The management of patients with third molar teeth. Faculty of Dental Surgery of the Royal College of Surgeons September 1997.

# Evidence
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 third molar carries risk for the patient, including temporary or permanent nerve damage, alveolar osteitis, infection and haemorrhage as well as temporary local swelling, pain and restricted mouth opening. There are also risks associated with the need for general anaesthesia 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.
A list of the source documentation and opinion made available to the Appraisal Committee is attached as appendix B.# Implications for the NHS
Given the uncertainty in current rates of prophylactic removal of pathology-free impacted third molars, it is difficult to precisely quantify the budget impact of discontinuation of this practice. However, based on 1994/95 data, this could result in an opportunity to release capacity in the specialty with a value of up to 5 million (NHS in England & Wales)
The number of patients waiting for this operation, in England and Wales might change, if waiting lists are reviewed using this guidance.# Further research
There are two ongoing randomised controlled trials (in the United States and in Denmark) comparing prophylactic extraction of wisdom teeth with management by deliberate retention. The results of these trials will be reviewed by the Institute to establish whether they have a material impact on this guidance.# Review of Guidances
Information on the review of the guidance on this technology is available on the NICE website.
Andrew DillonChief ExecutiveMarch 2000# Appendix C. Wisdom Teeth Removal  Patient Notes

# What is NICE guidance?
The National Institute for Clinical Excellence (NICE) is a part of the NHS. It has a team of experts who produce guidance for both the NHS and patients on medicines, medical equipment and clinical procedures.
When the Institute evaluates these things, it is called an appraisal. Each appraisal takes around 12 months to complete and involves the manufacturers of the technology, patient groups and professional organisations.
NICE was asked to look at wisdom teeth removal and provide guidance to the NHS which will help dentists and surgeons decide when wisdom teeth should be removed.

# What are Wisdom Teeth and why are they operated on?
Adult teeth normally come through from the age of 6 upwards, with the wisdom teeth being the last to arrive (usually between the ages of 18 & 24 years).
Sometimes, as wisdom teeth come through they cause problems. The term used to describe wisdom teeth that don't come through normally is impacted wisdom teeth. Two reasons for this are a lack of space, or other teeth being in the way.
For most people, impacted wisdom teeth cause no problems at all, but some people can suffer problems such as inflammation of the surrounding gum, a higher risk of tooth decay, gum disease in other teeth, and possibly problems with teeth in later life.
Removal of wisdom teeth is one of the most common operations carried out in the UK. Impacted wisdom teeth have sometimes been removed whether or not they were causing problems. There is no reliable evidence to suggest that operating on impacted wisdom teeth that are not causing problems has any benefit for the patient.
In fact every operation has some risk.

# What do NICE recommend about the removal of Wisdom Teeth?
Based on the evidence, NICE has recommended to the NHS that:
. Impacted wisdom teeth that are free from disease (healthy) should not be operated on. There are two reasons for this
a) There is no reliable research to suggest that this practice benefits patients
b) Patients who do have healthy wisdom teeth removed are being exposed to the risks of surgery.
These can include:
nerve damage
damage to other teeth
infection
bleeding and, rarely, death
Also, after surgery to remove wisdom teeth, patients may:
have swelling and pain
be unable to open their mouth fully
. Patients who have impacted wisdom teeth that are not causing problems should visit their dentist for their usual check-ups.
. Only patients, who have diseased wisdom teeth, or other problems with their mouth, should have their wisdom teeth removed.
Your dentist or oral surgeon will be aware of the sort of disease or condition which would require you to have surgery. Examples include:
untreatable tooth decay
abscesses
cysts or tumours
disease of the tissues around the tooth
if the tooth is in the way of other surgery

# What should I do?
If you or a member of your family or someone you care for are having problems with their wisdom teeth you should discuss this with your dentist or surgeon.

# Will NICE review its guidance?
Yes. The guidance will be reviewed in March 2003.
There is further research underway in this area. The results of this will be reviewed by NICE to decide if this guidance needs to be updated before 2003.
ISBN: 978-1-4731-3148-4