Most Patients With Asymptomatic, Disease-Free Third Molars Elect Extraction Over Retention as Their Preferred Treatment

doi:10.1016/j.joms.2010.07.058

Journal of Oral and Maxillofacial Surgery

Volume 68, Issue 12, December 2010, Pages 2935-2942

https://doi.org/10.1016/j.joms.2010.07.058 Get rights and content

Purpose

To answer the clinical question, “Among patients presenting for evaluation of their third molars (M3s), do those who choose M3 extraction, compared with those who choose M3 retention, differ in important demographic, clinical, anatomic, or radiographic ways?”

Materials and Methods

The investigators implemented a retrospective cohort study and enrolled a sample composed of patients presenting for M3 evaluation. The primary predictor variable was the clinician's assessment of M3 status categorized as asymptomatic, disease free (Sx–/D–); asymptomatic, disease present (Sx–/D+); symptomatic, disease free (Sx+/D–); and symptomatic, disease present (Sx+/D+). The secondary predictor variable was treatment recommendation grouped as extraction, retention, or patient choice. The primary outcome variable was the subject's treatment decision: extract or retain M3s. Data analyses were performed using bivariate and multiple regression methods.

Results

The study sample comprised 249 subjects (855 M3s) with a mean age of 27.3 ± 10.4 (median = 25.0) years. Of the 855 M3s evaluated, 37.3% were Sx–/D–, 0.6% were Sx+/D–, 51.1% were Sx–/D+, and 11.0% were Sx+/D+. The treatment recommendations were retention (6.5%), extraction (55.7%), or patient choice (37.8%). Subjects chose M3 extraction 82.1% of the time. In the adjusted multiple logistic regression model, increasing age, presence of Sx–/D– M3s, and a treatment recommendation of M3 retention were factors statistically (P < .05) associated with subject treatment choice of M3 retention.

Conclusion

When offered the choice of retention or extraction, most patients (60%) with asymptomatic, disease-free M3s elected for extraction. When M3 symptoms or disease were present, more than 95% of patients chose extraction as the preferred treatment.

Section snippets

Study Design and Sample

To address the research objectives, the investigators designed a retrospective cohort study. The study sample was derived from the population of patients presenting to the Department of Oral and Maxillofacial Surgery at the Massachusetts General Hospital between November 2008 and August 2009 for the evaluation and management of M3s by the senior author (T.B.D.). Subjects eligible for study inclusion had at least 1 third molar to be evaluated. Subjects were excluded from the study sample if

Results

During the study interval, 256 subjects with 882 M3s were evaluated. The investigators excluded 7 subjects (27 M3s) because they failed to meet the study inclusion requirements. The most common reason for exclusion was that the subjects had not chosen a treatment preference (ie, retention or extraction), at the time data were abstracted.

The final study sample was composed of 249 subjects (855 M3s) with a mean age of 27.3 ± 10.4 years (median = 25.0), and 142 (57.0%) were women. Table 2 includes

Discussion

The management of asymptomatic, disease-free M3s is a controversial topic, with passionate advocates for either M3 retention or extraction to prevent future problems. Obviously, one cannot perform both treatments, and the data supporting either option are not compelling. Although several studies report on patients with asymptomatic M3s, few document or report on the clinical management or the frequency of asymptomatic, disease-free (Sx–/D–) M3s.14, 15, 16 Current literature provides

References (23)

W. Adeyemo
Do pathologies associated with impacted lower third molars justify prophylactic removal?A critical review of the literature
Oral Surg Oral Med Oral Pathol
(2006)
R. Weyant
No evidence to support removal of asymptomatic impacted third molars in adolescents or adults
J Evid Based Dent Pract
(2007)
C.M. Hill et al.
Conservative, non-surgical management of patients presenting with impacted lower third molars: A 5-year study
Br J Oral Maxillofac Surg
(2006)
N. von Wowern et al.
The fate of impacted lower third molars after the age of 20A four-year clinical followup
Int J Oral Maxillofac Surg
(1989)
I. Venta et al.
Long-term evaluation of estimates of need for third molar removal
J Oral Maxillofac Surg
(2000)
S.K. Chuang et al.
Age as a risk for third molar surgery complications
J Oral Maxillofac Surg
(2007)
L. Halpern et al.
A comparison of 2 consultation and treatment strategies to manage impacted third molars
J Oral Maxillofac Surg
(2003)
C. Phillips et al.
Risk factors associated with prolonged recovery and delayed healing after third molar surgery
J Oral Maxillofac Surg
(2003)
J.P. Rood et al.
The radiological prediction of inferior alveolar nerve injury during third molar surgery
Br J Oral Maxillofac Surg
(1990)
C.M. Hill et al.
Conservative, non-surgical management of patients presenting with impacted lower third molars: A 5-year study
Br J Oral Maxillofac Surg
(2006)

N. von Wowern et al.

The fate of impacted lower third molars after the age of 20A four-year clinical followup

Int J Oral Maxillofac Surg

(1989)

Cited by (17)

Management of Impacted Third Molars
2020, Oral and Maxillofacial Surgery Clinics of North America
Citation Excerpt :
Treatment may range from oral hygiene care to restorative treatment, periodontal therapy, coronectomy, or extraction. Patients presenting with symptoms purportedly related to third molars but showing no evidence of related disease are seen less frequently than patients in groups A, C, and D.39 Management of these patients can be perplexing. Sometimes patients in group B report vague pain associated with an erupting third molar.
Effect of quality of life measures on the decision to remove third molars in subjects with mild pericoronitis symptoms
2014, Journal of Oral and Maxillofacial Surgery
To assess how quality of life (QoL) measures affect the decision for third molar (3M) removal in patients with mild symptoms of pericoronitis.
Healthy subjects, aged 18 to 35 years, with mild symptoms of pericoronitis were enrolled in an institutional review board–approved study. The demographic, clinical, and QoL data were collected at enrollment. The subjects voluntarily scheduled surgery for 3M removal. The principal outcome variable was their decision to undergo or not undergo surgery within 6 months of enrollment. The possible predictor variables in a multivariate logistic regression analysis were the demographic characteristics, dental insurance, and QoL measures.
The mean age of the 113 subjects was 23.2 ± 3.8 years. Of the 113 subjects, 79 elected to undergo 3M removal within 6 months of enrollment (removed group) and 34 elected to retain their 3M at 6 months after enrollment (retained group). A significantly greater proportion of the removed group were white (58% vs 35%; P = .03) and reported having at least “a little trouble” with opening their mouths (38% vs 18%; P = .04) and taking part in social life (27% vs 6%; P = .01). The multivariate logistic regression model suggested the odds of electing 3M removal within 6 months of enrollment were greater for those who were white (odds ratio [OR] 2.69, 95% confidence interval [CI] 1.14 to 6.32) and those who had at least “a little trouble” with interactions in their social life (OR 3.22, 95% CI 1.08 to 9.58).
In subjects with mild pericoronitis symptoms, experiencing problems with oral function and lifestyle, factors not often considered by clinicians, were significantly associated with subjects' decision for early 3M removal.
The indications for third-molar extractions
2014, Journal of the American Dental Association
Citation Excerpt :
The visible presence of third molars in young adults was associated significantly with periodontal inflammatory disease in teeth other than third molars.9 Researchers in prospective studies of occlusal caries in patients with asymptomatic third molars reported an increasing frequency of caries with increasing age and erupted third molars.10,11 Shugars and colleagues11 reported that 28 percent of 303 asymptomatic patients had at least one third molar with occlusal caries at baseline (39 percent in patients ≥ 25 years old).
Defining the indications for third- molar extraction continues to be a topic of controversy.
The dentist's management of third molars commonly hinges on identifying the presence of symptoms or disease that clearly is attributable to the third molar. Use of a guide that serves as a systematic and unambiguous way to classify third molars has been advocated.
Patients’ symptoms are designated as present and attributable to the third molar (Sx+) or as absent (Sx−). In addition, clinical or radiographic evidence of disease is evaluated and designated as present (D+) or absent (D−).
Evidence-based clinical data developed from prospective investigations have shown that an asymptomatic third molar does not necessarily reflect the absence of disease.
Current data are not sufficient to refute or support prophylactic extraction versus active surveillance for the routine management of third molars that are asymptomatic and free of disease (group D). Although decisions regarding third-molar management usually are straightforward, the evidence supporting extraction versus retention of asymptomatic disease-free (group D) third molars is lacking. Active surveillance, a prescribed program of follow-up and reassessment at regular intervals are recommended for retained third molars rather than waiting for the onset of symptoms.
The Management of the Asymptomatic, Disease-Free Wisdom Tooth: Removal Versus Retention
2012, Atlas of the Oral and Maxillofacial Surgery Clinics of North America
Surveillance as a management strategy for retained third molars: Is it desirable?
2012, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
M3s can be grouped into 4 categories using 2 axes, patient report of symptoms (present or absent) and clinical or radiographic evidence of disease (present or absent; Table 1).11
The purpose of the present report was to define and advocate active surveillance compared with follow-up as needed (prn follow-up), as the preferred management strategy for patients who elect to retain their third molars (M3s). Active surveillance, a nonoperative management strategy for retained M3s, is characterized as a prescribed, regularly scheduled set of follow-up visits that include both clinical and radiographic examinations. Given that the risk of complications with M3 removal are age related, the rationale for recommending active surveillance instead of “prn follow-up” is that the frequency of future disease among retained M3s is sufficiently high to warrant routine scheduled follow-up visits to detect and treat disease before it becomes symptomatic. Symptomatic disease is a late finding. Patients electing active surveillance as their preferred management strategy might not avoid operative treatment in the future, but it should increase their chances of being diagnosed at the youngest age possible, thus minimizing the age-related operative complications. The author recommends that the frequency of follow-up visits be approximately every 24 months and the examination be completed by a specialist or general dentist. Active surveillance as a management strategy is based on level 5 evidence (ie, expert opinion).
How many patients have third molars and how many have one or more asymptomatic, disease-free third molars?
2012, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Conversely, 29% (119 subjects) were asymptomatic and free of disease. The second estimate was from the study of Kinard and Dodson9 that estimated the frequency of Sx−/D− M3s in a sample of 249 subjects (855 M3s) referred for evaluation and management of M3s to a tertiary care center. The median age of the sample was 25 years, and 57% were women.
The purpose of this report was to summarize the frequencies of third molars (M3s) in general and asymptomatic, disease-free M3s specifically. Estimates of M3 prevalence range so widely (ie, 6.0% to 96%) as to be of little use. The estimates vary depending on definitions, age, clinical versus radiographic assessment, and patient versus population samples. For patient management, it may be more valuable to estimate the prevalence of M3s grouped by clinical rather than anatomic status. Many times, however, M3s are categorized simply as asymptomatic. In many pathologic processes, from cancer to cardiovascular disease, the term asymptomatic does not equal an absence of disease. As such, M3s should be categorized based on symptom and disease status. Subjects with all M3s asymptomatic and absent of disease ranged from 12% in a sample of patients referred for M3 evaluation to 29% in a nonpatient volunteer sample. In the patient sample, 37% of the M3s evaluated were asymptomatic and free of disease.

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: This project was supported in part by the Oral and Maxillofacial Surgery Foundation Student Research Training Award (B.E.K.), Harvard Medical School Office of Enrichment Research Award (B.E.K.), Massachusetts General Hospital Department of Oral and Maxillofacial Surgery Education and Research Fund (B.E.K.), Center for Applied Clinical Investigation (T.B.D.), and Massachusetts General Physicians Organization (T.B.D.).

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Basic and patient-oriented researchMost Patients With Asymptomatic, Disease-Free Third Molars Elect Extraction Over Retention as Their Preferred Treatment

Purpose

Materials and Methods

Results

Conclusion

Section snippets

Study Design and Sample

Results

Discussion

Oral Surg Oral Med Oral Pathol

J Evid Based Dent Pract

Br J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Basic and patient-oriented research
Most Patients With Asymptomatic, Disease-Free Third Molars Elect Extraction Over Retention as Their Preferred Treatment