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The Management of the Asymptomatic, Disease-Free Wisdom Tooth: Removal Versus Retention

      The management of impacted third molars (M3s) or wisdom teeth is a decision encountered by oral and maxillofacial surgeons (OMSs) daily. The decision-making is usually very straightforward, owing to the presence of disease. A challenging management decision is how to manage the asymptomatic, disease-free wisdom tooth. For these types of M3s, the treatment is essentially a binary choice: (1) operative treatment (eg, extraction) or (2) retention.
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      Further readings

      A. Organizational positions on M3 management

      1. Available at: http://www.aaoms.org/docs/media/third_molars/wisdomteeth.pdf. Accessed December 28, 2011.

      2. Opposition to prophylactic removal of third molars (wisdom teeth). Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1371. Accessed December 28, 2011.

        • Mettes T.G.
        • Nienhuijs M.E.
        • van der Sanden W.J.
        • et al.
        Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults.
        Cochrane Database Syst Rev. 2005; (CD003879, Available at:) (Accessed December 28, 2011)

      B. Principles of evidence-based clinical decision-making and applications to M3 management

      1. Available at: http://www.cebm.net/index.aspx?o=1025. Accessed December 28, 2011.

      2. Available at: http://ebm.oscarmcmaster.org/curricula/mcmaster-cd-content/critical-appraisal-exercise. Accessed December 28, 2011.

        • Dodson T.B.
        Management of asymptomatic wisdom teeth: an evidence-based approach.
        in: Bagheri S.C. Bell R.B. Khan H.A. Current therapy in oral and maxillofacial surgery. Elesvier Saunders, St Louis (MO)2011: 122-126
        • Kinard B.E.
        • Dodson T.B.
        Most patients with asymptomatic, disease-free third molar elect extraction over retention as their preferred treatment.
        J Oral Maxillofac Surg. 2010; 68: 2935-2942
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        • Guyatt G.H.
        Progress in evidence-based medicine.
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        Evidence-based medicine: what it is and what it isn't.
        BMJ. 1996; 312: 71-72
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        • Dodson T.B.
        Impacted wisdom teeth.
        Clin Evid. 2010; 4: 1302

      C. Disease associated with retained M3s

        • Blakey G.H.
        • Jacks M.T.
        • Offenbacher S.
        • et al.
        Progression of periodontal disease in the second/third molar region in subjects with asymptomatic third molars.
        J Oral Maxillofac Surg. 2006; 64: 189-193
        • Blakey G.H.
        • Marciani R.D.
        • Haug R.H.
        • et al.
        Periodontal pathology associated with asymptomatic third molars.
        J Oral Maxillofac Surg. 2002; 60: 1227-1233
        • McArdle L.W.
        • Renton T.F.
        Distal cervical caries in the mandibular second molar: an indication for the prophylactic removal of the third molar?.
        Br J Oral Maxillofac Surg. 2006; 44: 42-45
        • Phillips C.
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        • Jaskolka M.
        • et al.
        Changes over time in position and periodontal status of retained third molars.
        J Oral Maxillofac Surg. 2007; 65: 2011-2017

      D. Predicting available space for M3 eruption

        • Venta I.
        • Murtomaa H.
        • Ylipaavalniemi P.
        A device to predict lower third molar eruption.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997; 84: 598-603
        • Venta I.
        • Schou S.
        Accuracy of the third molar eruption predictor in predicting eruption.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 91: 638-642

      E. Risk of future M3 extraction among retained M3s

        • Fernandes M.J.
        • Ogden G.R.
        • Pitts N.B.
        • et al.
        Actuarial life-table analysis of lower impacted wisdom teeth in general dental practice.
        Community Dent Oral Epidemiol. 2010; 38: 58-67
        • Hill C.M.
        • Walker R.V.
        Conservative, non-surgical management of patients presenting with impacted lower third molars: a 5-year study.
        Br J Oral Maxillofac Surg. 2006; 44: 347-350
        • Phillips C.
        • White R.P.
        • Shugars D.A.
        • Zhou X.
        Risk factors associated with prolonged recovery and delayed healing after third molar surgery.
        J Oral Maxillofac Surg. 2003; 61: 1436-1448
        • Venta I.
        • Ylipaavalniemi P.
        • Turtola L.
        Clinical outcome of third molars in adults followed during 18 years.
        J Oral Maxillofac Surg. 2004; 62: 182-185
        • Venta I.
        • Ylipaavalniemi P.
        • Turtola L.
        Long-term evaluation of estimates of need for third molar removal.
        J Oral Maxillofac Surg. 2000; 58: 288-291
        • von Wowern N.
        • Nielsen H.O.
        The fate of impacted lower third molars after the age of 20. A four-year clinical followup.
        Int J Oral Maxillofac Surg. 1989; 18: 277-280

      F. Decision analyses supporting M3 retention

        • Brickley M.
        • Kay E.
        • Shepherd J.P.
        • Armstrong R.A.
        Decision analysis for lower-third-molar surgery.
        Med Decis Making. 1995; 15: 143-151
        • Edwards M.
        • Brickley M.
        • Goodey R.
        • Shepherd J.
        The cost, effectiveness, and cost-effectiveness of removal and retention of asymptomatic, disease-free third molars.
        Br Dent J. 1999; 187: 380-384
        • Song F.
        • O'Meara S.
        • Wilson P.
        • et al.
        The effectiveness and cost-effectiveness of prophylactic removal.
        Health Technol Assess. 2000; 4: 1-55
        • Tulloch J.
        • Antczak-Bouckoms A.
        • Ung N.
        Evaluation of the costs and relative effectiveness of alternative strategies for the removal of mandibular third molars.
        Int J Technol Assess Health Care. 1990; 6: 505-515
        • Tulloch J.
        • Antczak-Bouckoms A.
        Decision analysis in the evaluation of clinical strategies for the management of mandibular third molars.
        J Dent Educ. 1987; 51: 652-660