Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth

  • Conclusions changed
  • Review
  • Intervention

Authors

  • Hossein Ghaeminia,

    Corresponding author
    1. Radboud University Medical Center, Department of Oral and Maxillofacial Surgery, Nijmegen, Netherlands
    2. Rijnstate Hospital, Department of Oral and Maxillofacial Surgery, Arnhem, Netherlands
    • Hossein Ghaeminia, Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 14, Nijmegen, 6525 GA, Netherlands. hos.ghaeminia@gmail.com.

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  • John Perry,

    1. Cardiff University School of Dentistry, Department of Orthodontics, Cardiff, UK
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  • Marloes EL Nienhuijs,

    1. Radboud University Medical Center, Department of Oral and Maxillofacial Surgery, Nijmegen, Netherlands
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  • Verena Toedtling,

    1. The University of Manchester, Department of Oral and Maxillofacial Surgery, Division of Dentistry, Faculty of Biology, Medicine and Health, Manchester, UK
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  • Marcia Tummers,

    1. Radboud University Medical Center, Radboud Institute for Health Sciences, Department for Health Evidence, Nijmegen, Netherlands
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  • Theo JM Hoppenreijs,

    1. Rijnstate Hospital, Department of Oral and Maxillofacial Surgery, Arnhem, Netherlands
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  • Wil JM Van der Sanden,

    1. Radboud University Medical Center, Department of Quality and Safety of Oral Health Care, College of Dental Science, Nijmegen, Netherlands
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  • Theodorus G Mettes

    1. The National Institute for Development of Clinical Practices Guidelines in Oral Care (KiMo), Utrecht, Netherlands
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Abstract

Background

Prophylactic removal of asymptomatic disease-free impacted wisdom teeth is surgical removal of wisdom teeth in the absence of symptoms and with no evidence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease (periodontitis), caries and the development of cysts and tumours. When surgical removal is carried out in older people, the risk of postoperative complications, pain and discomfort is increased. Other reasons to justify prophylactic removal of asymptomatic disease-free impacted third molars have included preventing late lower incisor crowding, preventing damage to adjacent structures such as the second molar or the inferior alveolar nerve, in preparation for orthognathic surgery, in preparation for radiotherapy or during procedures to treat people with trauma to the affected area. Removal of asymptomatic disease-free wisdom teeth is a common procedure, and researchers must determine whether evidence supports this practice. This review is an update of an existing review published in 2012.

Objectives

To evaluate the effects of removal compared with retention (conservative management) of asymptomatic disease-free impacted wisdom teeth in adolescents and adults.

Search methods

We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 24 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 4), MEDLINE Ovid (1946 to 24 May 2016) and Embase Ovid (1980 to 24 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing and unpublished studies to 24 May 2016. We imposed no restrictions on language or date of publication in our search of electronic databases.

Selection criteria

Studies comparing removal (or absence) with retention (or presence) of asymptomatic disease-free impacted wisdom teeth in adolescents or adults. We included randomised controlled trials (RCTs) with no restriction on length of follow-up, if available. We considered quasi-RCTs and prospective cohort studies for inclusion if investigators measured outcomes with follow-up of five years or longer.

Data collection and analysis

Eight review authors screened search results and assessed the eligibility of studies for inclusion according to the review inclusion criteria. Eight review authors independently conducted risk of bias assessments in duplicate. When information was unclear, we contacted study authors for additional information.

Main results

This review includes two studies. The previous review included one RCT with a parallel-group design, which was conducted in a dental hospital setting in the United Kingdom; our new search for this update identified one prospective cohort study conducted in the private sector in the USA.

Primary outcome

No eligible studies in this review reported the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth on health-related quality of life

Secondary outcomes

We found only low to very low quality evidence of the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth for a limited number of secondary outcome measures.

One prospective cohort study, reporting data from a subgroup of 416 healthy male participants, aged 24 to 84 years, compared the effect of the absence (previous removal or agenesis) against the presence of asymptomatic disease-free impacted wisdom teeth on periodontitis and caries associated with the distal of the adjacent second molar during a follow-up period of three to over 25 years. Very low quality evidence suggests that the presence of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting the adjacent second molar in the long term. In the same study, which is at serious risk of bias, there is insufficient evidence to demonstrate a difference in caries risk associated with the presence or absence of impacted wisdom teeth.

One RCT with 164 randomised and 77 analysed adolescent participants compared the effect of extraction with retention of asymptomatic disease-free impacted wisdom teeth on dimensional changes in the dental arch after five years. Participants (55% female) had previously undergone orthodontic treatment and had 'crowded' wisdom teeth. No evidence from this study, which was at high risk of bias, was found to suggest that removal of asymptomatic disease-free impacted wisdom teeth has a clinically significant effect on dimensional changes in the dental arch.

The included studies did not measure our other secondary outcomes: costs, other adverse events associated with retention of asymptomatic disease-free impacted wisdom teeth (pericoronitis, root resorption, cyst formation, tumour formation, inflammation/infection) and adverse effects associated with their removal (alveolar osteitis/postoperative infection, nerve injury, damage to adjacent teeth during surgery, bleeding, osteonecrosis related to medication/radiotherapy, inflammation/infection).

Authors' conclusions

Insufficient evidence is available to determine whether or not asymptomatic disease-free impacted wisdom teeth should be removed. Although asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is of very low quality. Well-designed RCTs investigating long-term and rare effects of retention and removal of asymptomatic disease-free impacted wisdom teeth, in a representative group of individuals, are unlikely to be feasible. In their continuing absence, high quality, long-term prospective cohort studies may provide valuable evidence in the future. Given the lack of available evidence, patient values should be considered and clinical expertise used to guide shared decision making with patients who have asymptomatic disease-free impacted wisdom teeth. If the decision is made to retain asymptomatic disease-free impacted wisdom teeth, clinical assessment at regular intervals to prevent undesirable outcomes is advisable.

Plain language summary

Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth

Review question

This review, produced through Cochrane Oral Health, seeks to assess the effects of removal compared with conservative management of impacted wisdom teeth, in the absence of symptoms and without evidence of local disease, in adolescents and adults. This is an update of an existing review published in 2012.

Background

Wisdom teeth, or third molars, generally erupt between the ages of 17 and 26 years. These are the last teeth to erupt, and they normally erupt into a position closely behind the last standing teeth (second molars). Space for these teeth to erupt can be limited. Wisdom teeth often fail to erupt or erupt only partially, which is often due to impaction of the wisdom teeth against the second molars (teeth directly in front of the wisdom teeth). In most cases, this occurs when second molars are blocking the path of eruption of third molar teeth and act as a physical barrier, preventing complete eruption. An impacted wisdom tooth is called asymptomatic and disease-free in the absence of signs and symptoms of disease affecting the wisdom tooth or nearby structures.

Impacted wisdom teeth can cause swelling and ulceration of the gums around the wisdom teeth, damage to the roots of second molars, decay in second molars, gum and bone disease around second molars and development of cysts or tumours. General agreement exists that removal of wisdom teeth is appropriate if signs or symptoms of disease related to the wisdom teeth are present. Less agreement exists about the appropriate management of asymptomatic disease-free impacted wisdom teeth.

Study characteristics

We searched the medical literature up to May 2016 and found one randomised controlled trial (RCT) and one prospective cohort study to include in this review. These studies involved 493 participants in total. The RCT conducted at a dental hospital in the UK included 77 adolescent male and female participants, and the cohort study conducted at a private dental clinic in the USA involved 416 men aged 24 to 84 years.

Key results

Available evidence is insufficient to show whether or not asymptomatic disease-free impacted wisdom teeth should be removed.

One study at serious risk of bias provided very low quality evidence suggesting that the presence of asymptomatic disease-free impacted wisdom teeth is associated with increased risk of periodontitis (infection of the gums) affecting the adjacent second molar (teeth directly in front of the wisdom teeth) in the long term. In the same study, no evidence was found to suggest that the presence of asymptomatic disease-free impacted wisdom teeth increases the risk of caries affecting the adjacent second molar.

Another study, also at high risk of bias, found no evidence to suggest that removal of asymptomatic disease-free impacted wisdom teeth has an effect on crowding in the dental arch.

The included studies did not measure our primary outcome - health-related quality of life. Nor did they measure our secondary outcomes - costs, other adverse events associated with retention of asymptomatic disease-free impacted wisdom teeth (pericoronitis, root resorption, cyst formation, tumour formation, inflammation/infection) and adverse effects associated with their removal (alveolar osteitis/postoperative infection, nerve injury, damage to adjacent teeth during surgery, bleeding, osteonecrosis related to medication/radiotherapy, inflammation/infection).

Quality of the evidence

Evidence provided by the two studies included in this review is of low to very low quality, so we cannot rely on these findings. High-quality research is urgently needed to support clinical practice in this area. In light of the lack of available evidence, patient values should be considered and clinical expertise used when treatment decisions are made with patients who have asymptomatic disease-free impacted wisdom teeth. If the decision is made to retain asymptomatic disease-free impacted wisdom teeth, clinical assessment at regular intervals is advisable to prevent undesirable outcomes.

Ringkasan bahasa mudah

prosedur teknik surgikal berbanding konsevatif untuk pengendalian gigi geraham bongsu terimpak yang asimptomatik bebas-penyakit.

Soalan ulasan

Ulasan ini merujuk kepada buktiKesihatan Oral Cochrane bertujuan menilai kesan pembuangan (prosedur surgikal) berbanding pengendalian konservatif gigi geraham bongsu terimpak, tanpa gejala dan tanpa bukti penyakit setempat dalam kalangan remaja dan orang dewasa. Ini adalah kemaskini terbitan ulasan sedia ada pada 2012.

Latarbelakang

Gigi geraham bongsu atau molar ketiga biasanya mereput dan tercabut di antara umur 17 dan 26 tahun.Ia merupakan gigi terakhir untuk mereput, dan kerapkali mereput dalam posisi rapat dengan gigi paling hujung di dalam mulut (molar kedua)Ruang untuk gigi-gigi ini sangat terhad.Gigi geraham bongsu sering gagal untuk mereput atau separa mereput, akibat impak gigi geraham bongsu terhadap molar kedua (gigi di hadapan gigi geraham bongsu) Dalam kebanyakan kes, ia terjadi bila molar kedua menghalang laluan pengeruptan molar ketiga dan berperanan sebagai halangan fizikal, menghalang pereputan sepenuhnya.Gigi geraham bongsu yang terimpak dipanggil asimptomatik atau bebas-penyakit jika tiada tanda dan gejala penyakit yang mempengaruhi gigi tersebut atau struktur berhampirannya.

Gigi geraham bongsu terimpak boleh menyebabkan bengkak dan ulser pada gusi sekeliling gigi tersebut, kerosakan pada akar molar kedua, kerosakan molar kedua, penyakit gusi dan tulang di sekekeliling molar kedua dan pembentukan sista atau tumor. Terdapat persetujuan umum bahawa pembuangan gigi geraham bongsu sesuai jika ada tanda dan gejala penyakit yang dikaitkan dengan gigi geraham bongsu tersebut. Kurang persetujuan wujud berkenaan pengendalian yang sesuai untuk gigi geraham bongsu terimpak yang asimptomatik dan bebas-penyakit.

Ciri kajian

Kami mencari tulisan perubatan sehingga May 2016 dan mendapat satu kajian rawak terkawal (KRT) dan satu kajian kohort prospektif untuk dimasukkan dalam ulasan ini. Kajian-kajian ini melibatkan 493 jumlah responden.KRT yang dijalankan di hospital pergigian di UK melibatkan 77 peserta remaja lelaki dan wanita, dan kajian kohort yang dijalankan di sebuah klinik swasta di AS melibatkan 416 responden yang berumur 24 hingga 84 tahun.

Keputusan utama

Bukti sedia ada tidak mencukupi untuk membuktikan sama ada gigi geraham bongsu terimpak asimptomatik bebas-penyakit patut dibuang.

Satu kajian yang tidak ada elemen ketidakadilan memberi kualiti bukti yang rendah menyatakan kehadiran gigi geraham bongsu terimpak yang asimptomatik bebas-penyakit dikaitkan dengan periodontitis (jangkitan gusi) dan mempengaruhi molar kedua yang bersebelahan (gigi yang di hadapan gigi geraham bongsu) dalam jangkamasa panjang. Dalam kajian yang sama, tiada bukti untuk mencadangkan gigi geraham bongsu terimpak yang asimptomatik bebas-penyakit meningkatkan risiko karies yang boleh mempengaruhi molar kedua yang bersebelahan.

Kajian satu lagi, juga berisiko bias tinggi, tidak menemukan bukti untuk mencadangkan pembuangan gigi geraham bongsu terimpak memberi kesan terhadap kesesakan dalam rawatan pergigian.

Kajian-kajian tersebut tidak mengukur hasil utama kami - kualiti hidup berkaitan kesihatan. Kajian-kajian tersebut juga tidak mengukur hasil sekunder - kos, kesan buruk lain berkaitan pengekalan gigi geraham bongsu terimpak yang asimptomatik bebas-penyakit (perikoronitis, resorpsi akar, pembentukan sista, pembentukan tumor, keradangan/jangkitan) dan kesan buruk berkaitan dengan pembuangan (osteitis/jangkitan post-operatif, kecederaan saraf, kerosakan gigi bersebelahan semasa surgeri, perdarahan, osteoradionekrosis berkaitan ubatan/radioterapi, keradangan/jangkitan)

Kualiti bukti

Bukti yang dikemukan oleh kedua-dua kajian yang dimasukkan dalam ulasan ini adalah rendah hingga sangat rendah, oleh itu kami tidak dapat bergantung kepada penemuan ini. Kajian berkualiti tinggi sangat diperlukan untuk menyokong amalan klinikal dalam bidang ini. Oleh kerana kurangnya bukti, penilaian pesakit patut dipertimbangkan dan kepakaran klinikal digunakan apabila membuat keputusan untuk pesakit yang ada gigi geraham bongsu terimpak yang asimptomatik bebas-penyakit.Jika keputusan dibuat untuk mengekalkan gigi geraham bongsu terimpak yang asimptomatik bebas-penyakit, penilaian klinikal berjeda regular dinasihatkan untuk mencegah hasil yang tidak diingini.

Catatan terjemahan

Diterjemahkan oleh Noorliza Mastura Ismail (Kolej Perubatan Melaka-Manipal). Disunting Mohd. Shaharudin Shah Che Hamzah (Universiti Sains Malaysia). Untuk sebarang pertanyaan berkaitan terjemahan ini sila hubungi noorliza.mastura@manipal.edu.my