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Conservative, non-surgical management of patients presenting with impacted lower third molars: a 5-year study

Hill, C. Michael and Walker, Rita Valerie 2006. Conservative, non-surgical management of patients presenting with impacted lower third molars: a 5-year study. British Journal of Oral and Maxillofacial Surgery 44 (5) , pp. 347-350. 10.1016/j.bjoms.2005.08.014

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The removal of wisdom teeth has been the subject of much research in the UK. The complications and costs associated with the removal of unerupted or partially erupted third molars are considerable and the routine prophylactic removal of all impacted wisdom teeth has become unacceptable. Postoperative pain, swelling, and trismus are almost universal and the incidence of damage to both inferior dental and lingual nerve is relatively high. After the removal of lower third molars, 5–15% of patients have some temporary numbness of the anterior two-thirds of the tongue or the lower lip and chin. This numbness is thought to be permanent in about 0.5% of cases.1 At one time, patients waiting for removal of third molars comprised up to 90% of patients waiting for oral and maxillofacial surgery, although this figure has fallen rapidly (Demand for elective admission for selected procedures, 1991. Bristol South West Regional Health Authority, 1992). Access to elective surgery is often restricted, both manpower and resources being scarce in many parts of the world. Against such a background, it is essential that any treatment is both clinically effective and demonstrably efficient. As a result, there has been considerable debate recently about the need for the removal of impacted wisdom teeth.2, 3, 4, 5 and 6 The indications for the removal of third molars were the subject of a National Institutes of Health Consensus Conference held in the United States in 1979.7 The criteria for surgical intervention that were agreed were recurrent pericoronitis, caries not amenable to restorative measures, dentigerous cyst, internal or external resorption, and periodontal disease to which the third molar was contributing—remarkably similar to the criteria subsequently produced by the National Institute of Clinical Excellence (NICE) in the United Kingdom.8 The local (Cardiff) criteria were established in 1998 following a departmental audit and were largely those adopted by NICE. They also included wisdom teeth in a fracture line and those the removal of which was advised by a consultant orthodontist as part of an orthodontic treatment plan. The application of these principles since the late 1990s has led to a large number of teeth that previously would have been removed, being left alone. The outcome of such teeth is important as most surgeons would prefer to remove them from younger people if they are going to have to be removed at some time in a patient's lifetime (although there is no clinical research to support this). We have followed 228 patients (each with at least one conservatively managed lower third molar) for 5 years. Patients and methods With the approval of the local ethics research committee, young adults between the ages of 16 and 30 years were invited to take part in this study provided they had at least one impacted lower third molar and no criterion for its immediate removal. Consenting patients with partially erupted or unerupted third molars were included in the study after a full clinical and radiographic examination. The power calculation (based on various assumptions about the incidence of pericoronitis) indicated that a minimum of 200 patients would be needed to complete the study. Patients with one or more of the NIH (and subsequently NICE) or Cardiff criteria, those outside the declared age range, and those with fully erupted third molars were excluded from the study. Patients who were unwilling to be followed up for 5 years or who moved away from the geographical area were withdrawn. This reduced the total number of patients from the 250 originally recruited to 228 who completed the 5-year follow-up (or who were excluded following extraction of the tooth). At the initial appointment, a full history was taken and clinical and radiographic examinations were undertaken. These included: • eruption state • pericoronitis or history of pericoronitis • smoking • history of swelling • trismus • orthodontic considerations such as crowding or cross bites • the presence and location of any caries. The clinical examination was also used to record: • visible plaque • depth of pocket distal to the second molar • bleeding on probing • intra-bony defect • evaluation of the position of the upper third molar • any evidence of resorption • radiographic measurement of the follicular space Patients were telephoned every 6 months or sent a questionnaire if they could not be contacted by telephone. All patients were given access to a direct dial ‘hotline’ so they could get help in the event of any problems arising from their tooth or teeth. If any problems did arise, patients were reviewed, their revised history recorded and a new treatment plan devised. In the case of severe recurrent pericoronitis, patients were advised to have the third molar extracted. When pericoronitis was limited to a single episode, they were given the option of extraction, extraction of the maxillary third molar, or to “wait and see” if the condition resolved itself. Once a year, patients were reviewed in the clinic and had another full clinical examination. Further radiographs were taken when it was thought to be clinically appropriate. All the data were collected on specially designed record sheets; one copy was kept in the department and was tracked independently of the patient's hospital records. Modified forms were used for telephone interviews, which were used for symptom-free patients who did not wish to attend annually. Whereas a full clinical examination every 12 months would be ideal, the use of telephone interviewing is probably the reason for the relatively small loss of patients from the study and the patients were interviewed once a year until the study was completed 5 years later. The data were analysed by the SPSS® package using a variety of chi-square, odds ratios, and cross-tabulation tests. Results The female:male ratio was roughly 2:1 (150 women and 78 men) and the total number of mandibular third molars was 427, of which 19 teeth were fully erupted and the remainder about equally divided between unerupted and partially erupted teeth. Twenty-four mandibular third molars were absent. As this number was so low, analysis of data was on a ‘patient’ basis rather than per tooth. A total of 66 patients had a previous history of, or presented with, an episode of pericoronitis at their initial visit. Only two patients had any evidence of swelling at initial presentation and only one had any apparent trismus. No patients were referred for orthodontic reasons. Of these 66 patients, only 23 had extractions during the 5-year period (Table 1).

Item Type: Article
Date Type: Publication
Status: Published
Schools: Dentistry
Subjects: R Medicine > RK Dentistry
ISSN: 0266-4356
Last Modified: 23 Jul 2020 02:02

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