The management of wisdom teeth or third molars (M3s) can be challenging. The purpose of this chapter is to outline an evidence-based approach to the management of asymptomatic, disease-free wisdom teeth.
Anatomic and Clinical Definitions
For the purposes of this chapter, an impacted tooth is unlikely to erupt into a useful, functional position due to inadequate space to accommodate the tooth. An impacted tooth may be visible in the mouth. An impacted tooth may not be visible in the mouth but may be palpated with a periodontal probe. In this circumstance, the M3 is unerupted but chronically contaminated due to its communication with the oral cavity. An impacted tooth may not be visible or palpable with a periodontal probe, and it may be evident only on a radiograph.
An erupted tooth has reached the occlusal plane and has no evidence of an operculum. An erupted wisdom tooth may or may not be functional. An erupted wisdom tooth may or may not be hygienic, as evidenced by gingival inflammation or plaque accumulation. Please notice, in this chapter, there is no definition of a partially erupted M3. A partially erupted M3 could be considered impacted—that is, a static condition in which the tooth is unlikely to erupt into a useful functional position—or a dynamic condition with the tooth expected to erupt fully.
For the purposes of this chapter, M3s are classified based on the presence (or absence) of patient report of symptoms and the presence (or absence) of disease detected by physical or radiographic examination. Given these two categories, that is, symptom and disease status, M3s can be classified into four groups ( Box 13-1 ). The groups are (1) symptomatic and signs of disease present (Sx+/D+), (2) symptomatic and disease free (Sx+/D−), (3) asymptomatic and disease present (Sx−/D+), and (4) asymptomatic and disease free (Sx−/D−).
| DISEASE PRESENT | ||
|---|---|---|
| SYMPTOMS PRESENT | YES | NO |
| Yes | S+/D+ | S+/D− |
| No | S−/D+ | S−/D− |
The Sx+/D+ (symptomatic, disease present) group is recognized based on history and physical or radiographic examination, for instance, symptomatic pericoronitis, caries, or swelling or pain from a secondarily infected cystic lesion. The Sx+/D− (symptomatic, disease-absent) group is more subtle. Clinical examples include pain symptoms from teething in the setting of adequate space for the M3 to erupt into a useful, functional position and vague complaints of pain in the M3 region but no specific disease that explains well the symptoms. The Sx−/D+ (asymptomatic, disease present) group is also recognizable. The patient reports no symptoms, but disease is evident on clinical examination, for instance, soft tissue inflammation, caries, plaque accumulation, and increased probing depths, or on radiographic examination, for instance, cystic lesions, caries, internal resorption, or resorption or caries of adjacent teeth. The Sx−/D− (asymptomatic, disease-absent) group is also readily recognizable. By history, the patient reports no symptoms, and there are no signs of disease evident on physical or radiographic examination. In all of the above settings, the tooth may be erupted or impacted.
General Approaches to the Management of M3S
SX+/D+
Most patients in this group would benefit from operative intervention, ranging from restorative care to periodontal therapy to extraction, depending on the functional and hygienic status of the tooth and the ease or predictability of delivering care. At one extreme, based on the patient’s wishes, an erupted, functional, hygienic, clinically accessible M3 may be treated with the full scope of restorative care, including endodontic, periodontal, and prosthetic treatment. Conversely, many times, extraction may be the preferred option. There may be a role for medical management, for instance, symptomatic relief with antibiotics and analgesics in the setting where extraction may be contraindicated due to risk for nerve injury and the patient refuses coronectomy. Given multiple treatment options, and consistent with the principles of evidence-based care, patient interest, desire, and perception of risks, benefits, and costs need to be incorporated into the clinician’s decision-making process.
SX+/D−
While uncommon, there is a cohort of patients who have symptoms and signs of pericoronitis due to tooth eruption, but they appear to have adequate room for the teeth to erupt into a useful, functional position. In this setting, pericoronitis is a side effect of tooth eruption, not disease. Treatment options range from medical management with expectant monitoring to extraction. Discriminating between teething pain associated with a tooth that will erupt and pericoronitis of an impacted tooth can be challenging.
Predicting which M3s will erupt into a useful, functional position is a challenging and imperfect process. As such, both the patient and clinician need to be prepared to admit to an error in prognosis and be prepared to alter the treatment recommendation. For example, despite an initial preference for medical management, after multiple symptomatic episodes, a patient may elect extraction, despite the clinician’s assurance that there is a high likelihood that the symptomatic tooth will erupt into a useful, functional position. Alternatively, despite the radiographic assessment of adequate space, the clinician may note an absence of progress in eruption and now recommend extraction over expectant monitoring.
In some cases, pain symptoms may be attributed to the M3s, but there is no demonstrable clinical or radiographic disease. Extraction may be indicated to eliminate M3s from the differential diagnosis.
SX−/D+
This group of patients will be commonly encountered by oral and maxillofacial surgeons (OMSs). In a cohort of subjects of age 14 to 45 years with asymptomatic M3s, 25% of the study subjects had periodontal disease as evidenced by probing depths of greater than 5 mm. This group may also include patients with asymptomatic carious lesions, pericoronitis, or radiographic evidence of disease, for instance, radiolucent lesions or resorption of the M3 or the adjacent tooth. In this group, treatment is tailored to the patient’s needs and desires and ranges from restorative care to extraction.
SX−/D−
The remainder of this chapter is devoted to one of the more challenging decisions that the practicing OMS faces on a daily basis: how to manage the asymptomatic, disease-free M3. The key clinical question to answer is “Among patients with asymptomatic, disease-free (Sx−/D−) M3s, do those who elect M3 extraction to prevent problems in the future, when compared with those who elect M3 retention, have better outcomes?” Fortunately, there has been a systematic review of the topic summarized in the Cochrane Reviews and the answer is simple: “No evidence was found to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth in adults.”
Given the lack of high-quality evidence to direct care, what is the clinician to do? Evidence-based clinical decision making is not characterized by abandoning clinical responsibility in the absence of high-quality evidence. It is, instead, making clinical decisions with the best evidence available while incorporating patient preferences and desires, assessments of risks and benefits, costs and consequences into the decision-making process. In the case of asymptomatic, disease-free M3s, given the lack of evidence supporting M3 retention versus extraction, patient preference is the primary driving force in deciding treatment.
General Approaches to the Management of M3S
SX+/D+
Most patients in this group would benefit from operative intervention, ranging from restorative care to periodontal therapy to extraction, depending on the functional and hygienic status of the tooth and the ease or predictability of delivering care. At one extreme, based on the patient’s wishes, an erupted, functional, hygienic, clinically accessible M3 may be treated with the full scope of restorative care, including endodontic, periodontal, and prosthetic treatment. Conversely, many times, extraction may be the preferred option. There may be a role for medical management, for instance, symptomatic relief with antibiotics and analgesics in the setting where extraction may be contraindicated due to risk for nerve injury and the patient refuses coronectomy. Given multiple treatment options, and consistent with the principles of evidence-based care, patient interest, desire, and perception of risks, benefits, and costs need to be incorporated into the clinician’s decision-making process.
SX+/D−
While uncommon, there is a cohort of patients who have symptoms and signs of pericoronitis due to tooth eruption, but they appear to have adequate room for the teeth to erupt into a useful, functional position. In this setting, pericoronitis is a side effect of tooth eruption, not disease. Treatment options range from medical management with expectant monitoring to extraction. Discriminating between teething pain associated with a tooth that will erupt and pericoronitis of an impacted tooth can be challenging.
Predicting which M3s will erupt into a useful, functional position is a challenging and imperfect process. As such, both the patient and clinician need to be prepared to admit to an error in prognosis and be prepared to alter the treatment recommendation. For example, despite an initial preference for medical management, after multiple symptomatic episodes, a patient may elect extraction, despite the clinician’s assurance that there is a high likelihood that the symptomatic tooth will erupt into a useful, functional position. Alternatively, despite the radiographic assessment of adequate space, the clinician may note an absence of progress in eruption and now recommend extraction over expectant monitoring.
In some cases, pain symptoms may be attributed to the M3s, but there is no demonstrable clinical or radiographic disease. Extraction may be indicated to eliminate M3s from the differential diagnosis.
SX−/D+
This group of patients will be commonly encountered by oral and maxillofacial surgeons (OMSs). In a cohort of subjects of age 14 to 45 years with asymptomatic M3s, 25% of the study subjects had periodontal disease as evidenced by probing depths of greater than 5 mm. This group may also include patients with asymptomatic carious lesions, pericoronitis, or radiographic evidence of disease, for instance, radiolucent lesions or resorption of the M3 or the adjacent tooth. In this group, treatment is tailored to the patient’s needs and desires and ranges from restorative care to extraction.
SX−/D−
The remainder of this chapter is devoted to one of the more challenging decisions that the practicing OMS faces on a daily basis: how to manage the asymptomatic, disease-free M3. The key clinical question to answer is “Among patients with asymptomatic, disease-free (Sx−/D−) M3s, do those who elect M3 extraction to prevent problems in the future, when compared with those who elect M3 retention, have better outcomes?” Fortunately, there has been a systematic review of the topic summarized in the Cochrane Reviews and the answer is simple: “No evidence was found to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth in adults.”
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