evaluation of asymptomatic 3rd molars

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Evaluation and management of asymptomaticthird molars: Watchful monitoring is a low-riskalternative to extractionSanjivan KandasamyMidland, Western Australia, Australia

A lthough indications for the removal of symp-tomatic third molars are well established,a convincing case for the routine removal of unerupted asymptomatic, pathology-free third molarshas not been made. 1

Unlike the claims of Drs White and Prof t, theevidence-based literature points toward the watchfulmonitoring of asymptomatic third molars when there isno pathology. 1-4 Despite the various guidelines, reviews,and risks associated with these extractions, many clini-cians continue to routinely remove pathology-free thirdmolars. Until recently, this practice has been predicatedon reducing the risks of mandibular incisor crowdingand other complications developing in the future. Froman orthodontic standpoint, third molars have essentially nothing to do with mandibular incisor crowding. 5-12

Late incisor crowding is multifactorial, and factorsother than third molars play important roles. The removalof third molarson thesole basis of preventing mandibularincisor crowding is unsubstantiated and unjusti ed. Fur-thermore, the low incidence (1%-2%) of com-plications developing from impacted third molars, suchas odontogenic tumors, cysts, andmandibular angle frac-tures, also cannot be invoked to justify the removal of un-erupted and asymptomatic third molars on the groundthat at some poin t in the future these teeth will developrelated pathology. 13,14

According to Drs White and Prof t, there are 3 key criteria for the extraction of asymptomatic third mo-lars: periodontal disease, age, and informed consent. Let us discuss them individually as they relate to theevidence.

PERIODONTAL DISEASE

Over the past 2 decades, numerous studies have re-ported an association between periodontal disease andadverse pregnancy outcomes, 15,16 cardiovascular dis-ease,17 diabetes mellitus,18 various lung diseases such

as pneumonia and chronic obstructive lung disease,19

and Alzheimer s disease.20

Periodontal disease is a chronic disease state, and,although the mechanism behind the association withsystemic diseases is still unclear, it appears to be linkedto the production of cytokines and in ammatory medi-ators that eventually circulate systemically and possibly in uence other disease states.

Due to the limitations of many of these studies,a true causal relationship has been dif cult toestablish and in some cases has been discredited. For example, some studies failed to show a relation-

ship between periodontal disease and adversepregnancies. 21,22 Regardless, patients should be en-couraged to improve not only their oral health, but also their overall general health, including mak-ing appropriate lifestyle changes. This will improvetheir quality of life (QOL) as well as reduce the pos-sible deleterious effects of poor oral health on theirgeneral health.

According to the latest results from the AmericanAssociation of Oral and Maxillofacial Surgeons

(AAOMS) trials and the recent AAOMS Third Molar Multidisciplinary Conference, the AAOMS publishednew indications for the early removal of asymptomaticthird molars.23 These indications are based primarily onthe assumption that third molars will most likely bea site of periodontal disease in the future that mightthen contribute to systemic disease. The AAOMS nowrecommends the routine removal of asymptomaticthird molars virtually on this basis alone.

However, the key question here is how does the so-called medical signi cance of third molars t into theoverall scheme of dentistry and orthodontics?

There are many issues related to the latest AAOMSrecommendations:

Clinical senior lecturer in orthodontics, Dental School, University of WesternAustralia, Nedlands, Western Australia, Australia; visiting assistant professorin orthodontics, Center for Advanced Dental Education, Saint Louis University,St Louis, Mo; private practice, Midland, Western Australia, Australia. Reprint requests to: Sanjivan Kandasamy, Department of Orthodontics, DentalSchool, University of Western Australia, 17, Monash Ave, Nedlands, 6009, WA,Australia; e-mail, [email protected] J Orthod Dentofacial Orthop 2011;140:10-70889-5406/$36.00Copyright 2011 by the American Association of Orthodontists.doi:10.1016/j.ajodo.2011.05.008

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The AAOMS has dened a pocket depth of 4 mm ormore as pathologic disease. But is this depth really a health concern? Since some depth value must beassigned for investigative purposes, could not 3 or

5 mm easily be designated within a range of possiblepathology? What about factoring the position andthe unusual surrounding periodontal tissue con g-uration of especially the mandibular third molars?

What is the biologic burden of a pocket depth of 4mm or more in the overall general health picture? Let us put into perspective periodontal disease andits association with systemic diseases by using car-diovascular diseases, such as coronary artery disease,myocardial infarction, and strokes as examples. First, let us recall that studies to date have only shown an associational relationship between peri-

odontal disease and cardiovascular disease. Second,in these studies, all the subjects exhibited moderateto severe periodontal disease, unlike those in theAAOMS trials. Knowing this, we can put into per-spective the overplayed level of importance attachedto a 4 mm pocket at a third molar in relation to thehighly signi cant and well-established traditionalrisk factors associated with cardiovascular diseasesuch as obesity, family history, diet, age, sex, andsmoking.

By placingan exaggerated emphasis on the relation-ship between periodontal disease and systemic dis-

ease and linking this to the AAOMS

s self-servingarbitrary de nition of disease (pockets of 4 mm orgreater), the AAOMS claims that 70% of third molars will develop signi cant periodontal disease, there-fore recommending the routine removal of asymp-tomatic third molars. This is misleading andinappropriate.

Can we simply extract third molars on the basis thatif and when they develop pocketing of 4 mm orgreater in the future, they might indirectly initiateor in uence a plethora of systemic diseases? Whatabout other teeth with this degree of pocketing? Do they also need to be extracted?

What about options? What about each patient? What about periodontal therapy, maintenance, ormonitoring? What about recommendations regard-ing spending time educating our patients and preventing periodontal disease with proper oral andgeneral health advice and management?

Signi cant amounts of time and resources have been spent by the AAOMS producing and analyz-ing data to support the early routine removal of asymptomatic third molars. Little considerationhas been given to other well-established guide-

lines and studies around the world that differ intheir recommendations for the management of these teeth.

AGE

Age is a common factor in determining whenasymptomatic third molars should be removed. The ra-tionale is that early extractions are easier, less trau-matic, and reduce the likelihood of complications.These reasons at rst seem reasonable; however, thereare many other factors to also consider:

Not all third molars become symptomatic orpathologic.

Third molars generally improve in their angulationand position relative to the occlusal plane over time.

This improvementusuallyoccurs in the rst 3 decadesof life. Many unerupted thirdmolars that appear to bein a mesioangular position, for example, will actually straighten and erupt. 24,25 Therefore, there is thepotential of eruption in the fullness of time, and ex-tracting them early when patients are in their teenage years requires a more invasive surgical extractionprocedure, thereby increasing the likelihood of com-plications. On the other hand, many dentists andoral surgeons believe that extracting later when theroots are more developed will result in greater morbidity. A better way of assessing morbidity is rst to

consider the average proportion of third molars thatcan cause problems, which is about a third. We then weigh the pain associated with the extraction of allproblematic third molars against the usually recom-mended prophylactic removal of all nonproblematicor asymptomatic ones. The morbidity associated with this assessment is actually much less.26,27

Age per se is not a predisposing factor to increasedcomplications, but, rather, with increasing age, thereis an increase in health risk factors, which then in u-ence postoperative recovery. Risk factors includesmoking, sex, oral contraceptive use, experience of the surgeon, pathology associated with the thirdmolars before surgery, mandibular third mola rs vsmaxillary third molars, and deeper impactions.28-33

Furthermore, the study mentioned in the Point arti-cleassessed theeffects of age and sex on recovery af-ter third molar surgery.34 The study had somelimitations and unaccountedconfoundingvariables;however, between the 2 main age groups of 15.5 to18 and 21 to 29 years, it showed that the difference,on average, in surgery time was a few minutesgreater in the older group. The surgeons actually deemed the younger group slightly more dif cult.

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Recovery for all lifestyle and oral function items wasfound to be similar between the groups; after com-plex statistical analyses and manipulation, thegroups were shown to be at most slightly to moder-

ately different. Clinically, these differences were mi-nor at best. Advocating the earlier removal of thirdmolars on the sole basis that their future extraction will result in greater complications and morbidity issimply unfounded.

INFORMED CONSENT

The removal of unerupted, asymptomatic,pathology-free third molars is essentially an electiveprocedure. Because we have no way of identifying which teeth might become symptomatic in the future,

informed consent is a critical issue. As a general rule,the more elective the procedure, the greater the needfor adequate informed consent.

Patients need to be made aware of the possible risksnot only of pathology from retaining their asymptom-atic third molars, but also of complications arising fromtheir extractions. Today, patients demand more infor-mation and a better understanding before consentingto any treatment, especially for elective procedures.They need to be aware of the possibility of an overallimprovement in their QOL vs the immediate and possible long-term reduction in QOL as a result of surgery

and the associated complications. An improvement inQOL is most likely if patients had experienced symp-toms with their third molars preoperatively than if they did not. The likelihood of legal action is greaterif complications arise from surgery when the patientdid not hav e any preoperative signs or symptoms of disease.35,36 Legal action is almost guaranteed if com-plications arise, and the possible risks of pathology from retaining their asymptomatic third molars wereexaggerated, and if the risks of complications arisefrom the extractions were only touched upon or brie y discussed presurgically.

Based on the information we give to patients, their value of health can then be assessed: ie, what are they willing to sacri ce or risk, given their preoperativesymptoms, or lack of, to what they might gain inQOL postoperatively?37 Decision analysis models haveshown that oral surgeons , other dental professionals ,and patients perceptions of nonintervention were of greater importanc e than the incidence of problemsfrom third molars.37,38 Because of the chance of pa-thology and the probability of extraction complicationsand associated disability with each complication, the

authors concluded that third molars should only be ex-tracted if there is pathology. 37,38 The key is not to dis-miss the complications of extractions and theassociated morbidity and underestimate their impact

on the QOL of our patients. The

bottom line

fromdecision analysis is that letting sleeping dogs lie isthe best risk-minimizing option, and it has a greaterexpected payoff for the patient. As clinicians liablefor the decisions we make and the treatment recom-mendations we provide, we must rst put third molarperiodontal disease and age into perspective and thenask ourselves these questions before acceptingthe AAOMS s recommendations of prophylacticextractions:

What if the patient develops complications afterthird molar surgery?

Is taking action now on the basis of what if diseasedevelops justi able?

By extracting later, if and when required, willthe patient be signi cantly compromised den-tally?

What do the other evidence-based guidelines rec-ommend?

Will I be covered legally if a complication arises? Am I willing to recommend the routine extraction of third molars, knowing how weak the justi cation is,and therefore take responsibility for the conse-quences?

As a dentist or an oral surgeon, is one s recommenda-tion for extraction primarily a practice-managementdecision rather than a biologic one?

The key is to put into perspective the current evi-dence and give our patients all the information in a for-mat that they can understand to help them make themost appropriate informed decision that best suits theirneeds and concerns.

There are clear indications for the removal of thirdmolars associated with symptoms and pathology as well as guidelines for when the removal of asymptomaticpathology-free third molars is justi ed. But the sug-gested strategy of routine asymptomatic third molarextraction simply fails the test of evidence-based prac-tice, and it betrays our primary obligation as doctorsto rst do no harm. As noted by Drs White and Pro tt,Ash et al39 recommended the early extraction of all thirdmolars in the mid-20th century. Today, however, in the21st century, the routine removal of asymptomatic pa-thology-free third molars has become a dated practicethat is rapidly running out of valid excuses, and it hasno justi cation in contemporary dentistry and medicine.

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evaluation of asymptomatic 3rd molars

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