Task Force for Third Molar Summary. Summary of the Third Molar Clinical Trials: report of the AAOMS Task Force for Third Molar Summary

To prophylactically extract or not to extract partially erupted mesio-angularly impacted lower third molars?

Introduction Prophylactic removal of mesio-angularly impacted mandibular third molars (MAIM3Ms) has been discouraged by the National Institute for Health and Care Excellence in 2000. Consequently, partially erupted MAIM3Ms are retained for longer and only extracted if complications arise. The debate whether to extract prophylactically or to monitor these teeth is ongoing.Pathologies associated with retained partially erupted MAIM3Ms Retaining third molars long into adulthood has been associated with an increased risk of distal cervical caries and external root resorption of the second molar, periodontal disease and pericoronitis, among other pathologies. Although watchful monitoring can help to identify these pathologies, their nature often leads not only to a poor prognosis for the third molar, but also for the second molar, which then requires costly and time-consuming restorative or even prosthodontic work.Considering prophylactic extractions While an individual risk assessment is paramount, prophylactic removal of partially erupted MAIM3Ms has been shown to have positive effects on oral health-related quality of life, to relieve the pressure on secondary care services and to be economically feasible for the NHS.Conclusion While long-term prospective cohort studies are necessary to put an end to the ongoing controversy, patients' needs and wishes should be at the forefront of the provision of care.

Prophylactic removal of impacted mandibular third molars: a systematic review and economic evaluation

BACKGROUND

Impacted third molars are third molars that are blocked, by soft tissue or bone, from fully erupting through the gum. This can cause pain and disease. The treatment options for people with impacted third molars are removal or retention with standard care. If there are pathological changes, the current National Institute for Health and Care Excellence guidance states that the impacted third molar should be removed.

OBJECTIVE

The objective of this study was to appraise the clinical effectiveness and cost-effectiveness of the prophylactic removal of impacted mandibular third molars compared with retention of, and standard care for, impacted third molars.

METHODS

Five electronic databases were searched (1999 to 29 April 2016) to identify relevant evidence [The Cochrane Library (searched 4 April 2016 and 29 April 2016), MEDLINE (searched 4 April 2016 and 29 April 2016), EMBASE (searched 4 April 2016 and 29 April 2016), EconLit (searched 4 April 2016 and 29 April 2016) and NHS Economic Evaluation Database (searched 4 April 2016)]. Studies that compared the prophylactic removal of impacted mandibular third molars with retention and standard care or studies that assessed the outcomes from either approach were included. The clinical outcomes considered were pathology associated with retention, post-operative complications following extraction and adverse effects of treatment. Cost-effectiveness outcomes included UK costs and health-related quality-of-life measures. In addition, the assessment group constructed a de novo economic model to compare the cost-effectiveness of a prophylactic removal strategy with that of retention and standard care.

RESULTS

The clinical review identified four cohort studies and nine systematic reviews. In the two studies that reported on surgical complications, no serious complications were reported. Pathological changes due to retention of asymptomatic impacted mandibular third molars were reported by three studies. In these studies, the extraction rate for retained impacted mandibular third molars varied from 5.5% to 31.4%; this variation can be explained by the differing follow-up periods (i.e. 1 and 5 years). The findings from this review are consistent with the findings from previous systematic reviews. Two published cost-effectiveness studies were identified. The authors of both studies concluded that, to their knowledge, there is currently no economic evidence to support the prophylactic removal of impacted mandibular third molars. The results generated by the assessment group's lifetime economic model indicated that the incremental cost-effectiveness ratio per quality-adjusted life-year gained for the comparison of a prophylactic removal strategy with a retention and standard care strategy is £11,741 for people aged 20 years with asymptomatic impacted mandibular third molars. The incremental cost per person associated with prophylactic extraction is £55.71, with an incremental quality-adjusted life-year gain of 0.005 per person. The base-case incremental cost-effectiveness ratio per quality-adjusted life-year gained was found to be robust when a range of sensitivity and scenario analyses were carried out.

LIMITATIONS

Limitations of the study included that no head-to-head trials comparing the effectiveness of prophylactic removal of impacted mandibular third molars with retention and standard care were identified with the assessment group model that was built on observational data. Utility data on impacted mandibular third molars and their symptoms are lacking.

CONCLUSIONS

The evidence comparing the prophylactic removal of impacted mandibular third molars with retention and standard care is very limited. However, the results from an exploratory assessment group model, which uses available evidence on symptom development and extraction rates of retained impacted mandibular third molars, suggest that prophylactic removal may be the more cost-effective strategy.

FUTURE WORK

Effectiveness evidence is lacking. Head-to-head trials comparing the prophylactic removal of trouble-free impacted mandibular third molars with retention and watchful waiting are required. If this is not possible, routine clinical data, using common definitions and outcome reporting methods, should be collected.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016037776.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 30. See the NIHR Journals Library website for further project information.

An Unusual Case of Mandibular Squamous Cell Carcinoma in Intimacy with an Impacted Wisdom Tooth

Squamous cell carcinoma is the most common head and neck malignancy. It can occur in the mandible or maxilla without a preexisting oral mucosal lesion. Often, the clinical and radiographic presentation of SCC directs the clinician to favour malignancy over other pathological conditions. However, SCC may also mimic an infectious condition and therefore can pose a diagnostic challenge even for the most experienced clinicians. Herein, we report a case of mandibular squamous cell carcinoma in a 53-year-old male who presented with symptoms of right facial swelling, trismus, pain, and right-sided lip paresthesia. The patient underwent a surgical removal of the presumed infected third molar of the right mandible, but histopathological analysis of the associated soft tissue unexpectedly yielded squamous cell carcinoma. Given the biopsy-proven diagnosis, the patient received a mandibular resection of the tumor followed by primary reconstruction with a fibular free flap. Patients presenting with symptoms mimicking odontogenic infections should receive vigilant attention by clinicians with regard to the disease history, clinical signs, radiographic evidence, and decision for histopathological analysis. This is especially true in the context of impacted dentition, where malignancy must be considered when formulating a differential diagnosis.

Third Molars May Remain Free of Periodontal Pathology Among Well-educated Young Adults With Good Oral Health Practices

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Monitoring for periodontal inflammatory disease in the third molar region. Golden BA, Baldwin C, Sherwood C, Abdelbaky O, Phillips C, Offenbacher S, White RP, Jr.J Oral Maxillofac Surg 2015;73(4):595-9.

REVIEWER

Ventä Irja, DDS, PhD PURPOSE/QUESTION: Third molars were followed up at 2-year intervals to assess changes of periodontal status in initially asymptomatic third molars with no clinical evidence of periodontal pathology.

SOURCE OF FUNDING

This work was funded by the Oral & Maxillofacial Surgery Foundation, the American Association of Oral and Maxillofacial Surgeons, and the Department of Oral and Maxillofacial Surgery, University of North Carolina, Chapel Hill.

TYPE OF STUDY/DESIGN

Prospective cohort study

LEVEL OF EVIDENCE

Level 2: Limited-quality, patient-oriented evidence

STRENGTH OF RECOMMENDATION GRADE

Not applicable.