prophylactic removal of wisdom teeth
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The effectiveness and cost-effectiveness of prophylactic removal of wisdom teeth
F SongS O’MearaP WilsonS GolderJ Kleijnen
HTAHealth Technology Assessment NHS R&D HTA Programme
Health Technology Assessment 2000; Vol. 4: No. 15
Rapid review
Professor Sir Miles Irving*
Professor of Surgery, University of Manchester, Hope Hospital, Salford
Dr Sheila Adam Department of Health
Professor Angela Coulter Director, King’s Fund, London
Professor Anthony Culyer Deputy Vice-Chancellor,University of York
Dr Peter Doyle Executive Director, Zeneca Ltd, ACOST Committee on MedicalResearch & Health
Professor John Farndon Professor of Surgery, University of Bristol
Professor Charles Florey Department of Epidemiology & Public Health, NinewellsHospital & Medical School,University of Dundee
Professor HowardGlennester Professor of Social Science & Administration, LondonSchool of Economics & Political Science
Mr John H James Chief Executive, Kensington, Chelsea &Westminster Health Authority
Professor Michael Maisey Professor of Radiological Sciences, Guy’s, King’s & St Thomas’sSchool of Medicine & Dentistry,London
Mrs Gloria Oates Chief Executive, Oldham NHS Trust
Dr George Poste Chief Science & TechnologyOfficer, SmithKline Beecham
Professor Michael Rawlins Wolfson Unit of Clinical Pharmacology,University of Newcastle-upon-Tyne
Professor Martin Roland Professor of General Practice, University of Manchester
Professor Ian Russell Department of Health Sciences& Clinical Evaluation, University of York
Dr Charles Swan Consultant Gastroenterologist, North Staffordshire Royal Infirmary
* Previous Chair
Standing Group on Health Technology
Past members
Details of the membership of the HTA panels, the NCCHTA Advisory Group and the HTACommissioning Board are given at the end of this report.
Chair: Professor Kent WoodsProfessor of Therapeutics,University of Leicester
Professor Martin Buxton Director & Professor of Health Economics, Health Economics Research Group, Brunel University
Professor Shah EbrahimProfessor of Epidemiology of Ageing, University of Bristol
Professor Francis H CreedProfessor of Psychological Medicine,Manchester Royal Infirmary
Professor John Gabbay Director, Wessex Institute for Health Research & Development
Professor Sir John Grimley Evans Professor of Clinical Geratology, Radcliffe Infirmary, Oxford
Dr Tony Hope Clinical Reader in Medicine,Nuffield Department of Clinical Medicine, University of Oxford
Professor Richard Lilford Regional Director of R&D, NHS Executive West Midlands
Dr Jeremy Metters Deputy Chief Medical Officer,Department of Health
Professor Maggie PearsonRegional Director of R&D, NHS Executive North West
Mr Hugh Ross Chief Executive, The United Bristol Healthcare NHS Trust
Professor Trevor SheldonJoint Director, York HealthPolicy Group, University of York
Professor Mike SmithFaculty Dean of Research for Medicine, Dentistry,Psychology & Health, University of Leeds
Dr John Tripp Senior Lecturer in ChildHealth, Royal Devon and ExeterHealthcare NHS Trust
Professor Tom WalleyDirector, Prescribing Research Group,University of Liverpool
Dr Julie Woodin Chief Executive, Nottingham Health Authority
Current members
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HTA
The effectiveness and cost-effectiveness of prophylactic removal of wisdom teeth
F Song*
S O’MearaP WilsonS GolderJ Kleijnen
NHS Centre for Reviews and Dissemination, University of York, UK
*Corresponding author
Competing interests: none declared
Published July 2000
This report should be referenced as follows:
Song F, O’Meara S,Wilson P, Golder S, Kleijnen J.The effectiveness and cost-effectivenessof prophylactic removal of wisdom teeth. Health Technol Assess 2000;4(15).
Health Technology Assessment is indexed in Index Medicus/MEDLINE and ExcerptaMedica/EMBASE. Copies of the Executive Summaries are available from the NCCHTAwebsite (see overleaf).
The NHS Centre for Reviews and Dissemination was previously commissioned in 1996,by the Faculty of Dental Surgery of The Royal College of Surgeons of England, to producean assessment of published reviews. A version of this report appeared as:
Song F, Landes D, Glenny A, Sheldon T. Prophylactic removal of impacted third molars: anassessment of published reviews. Br Dent J 1997;182:339–46.
The review was updated for the Effectiveness Matters series in 1998: Prophylactic removalof impacted third molars: is it justified? Effectiveness Matters 1998;3(2).
NHS R&D HTA Programme
The overall aim of the NHS R&D Health Technology Assessment (HTA) programme is to ensurethat high-quality research information on the costs, effectiveness and broader impact of health
technologies is produced in the most efficient way for those who use, manage and work in the NHS.Research is undertaken in those areas where the evidence will lead to the greatest benefits topatients, either through improved patient outcomes or the most efficient use of NHS resources.
The Standing Group on Health Technology advises on national priorities for health technologyassessment. Six advisory panels assist the Standing Group in identifying and prioritising projects.These priorities are then considered by the HTA Commissioning Board supported by the NationalCoordinating Centre for HTA (NCCHTA).
The research reported in this monograph was commissioned by the HTA programme (projectnumber 99/16/01) on behalf of the National Institute for Clinical Excellence (NICE). Rapid reviewsare completed in a limited time to inform the appraisal and guideline development processesmanaged by NICE. The review brings together evidence on key aspects of the use of the technologyconcerned. However, appraisals and guidelines produced by NICE are informed by a wide range of sources. Any views expressed in this rapid review are therefore those of the authors and notnecessarily those of the HTA programme, NICE or the Department of Health.
Reviews in Health Technology Assessment are termed ‘systematic’ when the account of the search,appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permitthe replication of the review by others.
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Series Editors: Andrew Stevens, Ken Stein and John GabbayMonograph Editorial Manager: Melanie Corris
The editors have tried to ensure the accuracy of this report but cannot accept responsibility for anyerrors or omissions.
ISSN 1366-5278
© Crown copyright 2000
Enquiries relating to copyright should be addressed to the NCCHTA (see address given below).
Published by Core Research, Alton, on behalf of the NCCHTA.Printed on acid-free paper in the UK by The Basingstoke Press, Basingstoke.
Copies of this report can be obtained from:
The National Coordinating Centre for Health Technology Assessment,Mailpoint 728, Boldrewood,University of Southampton,Southampton, SO16 7PX, UK.Fax: +44 (0) 23 8059 5639 Email: hta@soton.ac.ukhttp://www.ncchta.org
Health Technology Assessment 2000; Vol. 4: No. 15
List of abbreviations .................................... i
Executive summary .................................... ii
1 Background ................................................... 1Introduction .................................................. 1Impacted third molars ................................ 1Pathological changes associated with impacted third molars ................................... 2Complications and risks following surgery .. 2
2 Aims and methodsAims ................................................................ 3Methods .......................................................... 3
3 Results ............................................................ 5Included studies ............................................. 5Excluded studies ............................................ 5Results from RCTs .......................................... 5Results from literature reviews ...................... 6Decision analyses for third molar surgery .... 7Cost and cost-effectiveness analysis ofprophylactic removal of third molars ........... 9
4 Discussion and conclusions ........................ 11Quality of available evidence ......................... 11Conclusions .................................................... 12
Acknowledgements .................................... 13
References ..................................................... 15
Appendix 1 Search strategies ...................... 19
Appendix 2 Summary of data extractionand quality assessment of RCTs ... ................ 21
Appendix 3 Summary of data extractionand methodological assessment of literature reviews ............................................ 25
Appendix 4 Data extraction summary fordecision analysis studies ................................. 39
Appendix 5 Studies excluded fromthe review ........................................................ 43
Contents
Health Technology Assessment 2000; Vol. 4: No. 15
i
List of abbreviations
3M(s) third molar(s)*
AL arch length*
CCTR Cochrane Controlled Trials Register
CI confidence interval*
DSD days of standard discomfort
ICW intercanine width*
LII Little’s Irregularity Index*
NICE National Institute for Clinical Excellence
RCT randomised controlled trial
SCI Science Citation Index
SD standard deviation*
SIGN Scottish Intercollegiate Guidelines Network
* Used only in tables
Health Technology Assessment 2000; Vol. 4: No. 15
iii
BackgroundRemoval of wisdom teeth is one of the mostcommon surgical procedures performed in theUK. Little controversy surrounds the removal ofimpacted third molars when they are associatedwith pathological changes such as infection, non-restorable carious lesions, cysts, tumours, anddestruction of adjacent teeth and bone. However,the justification for prophylactic removal ofimpacted third molars is less certain and has beendebated for many years.
Objectives
• To provide a summary of existing evidence onprophylactic removal of impacted wisdom teeth,in terms of the incidence of surgicalcomplications associated with prophylacticremoval, and the morbidity associated withretention.
Methods
A systematic review of the research literature wasundertaken.
Data sourcesAn existing review formed the basis of this report,and additional literature searches wereundertaken, including searches of electronicdatabases (MEDLINE, 1984–99; EMBASE, 1984–99;Science Citation Index, Cochrane Controlled TrialsRegister, National Research Register; Database ofAbstracts of Reviews of Effectiveness), papersources (including Clinical Evidence), and web-based resources. Relevant organisations andprofessional bodies were contacted for furtherinformation.
Study selectionStudies were selected for inclusion if they met thefollowing criteria:
• design – randomised controlled trials (RCTs),literature reviews, or decision analyses
• participants – people with unerupted orimpacted third molars, or those undergoing
surgical removal of third molars either asprophylaxis or due to associated pathologicalchanges
• reported outcomes – either the pathologicalchanges associated with retention of thirdmolars, or post-operative complicationsfollowing extraction.
There were no language restrictions on studyselection.
Data extraction and synthesisData from included studies were extracted intostructured tables and individual study validity wasassessed against methodological checklists. Datawere summarised descriptively. Decisions relatingto study selection, data extraction and validityassessment were made by two independentreviewers, and disagreements were resolved bydiscussion. For non-English papers, translatorswere recruited to assist with study selection anddata extraction.
Results
Forty studies were included in the review: twoRCTs, 34 literature reviews, and four decisionanalysis studies.
One RCT in the UK focused on the effects ofretained third molars on incisor crowding(predominantly a cosmetic problem) in patientswho had previously undergone orthodontictreatment. The results of this trial suggested thatthe removal of third molars to prevent late incisorcrowding cannot be justified. Another on-goingRCT in Denmark compares the effects and costs ofprophylactic removal of third molars with removalaccording to morbidity. So far, this trial hasrecruited 200 participants, and preliminary resultsindicate that watchful waiting may be a promisingstrategy. However, more data and longer follow-upof patients are needed to conclude whichtreatment strategy is the most cost-effective. It isalso known that a trial is on-going in the USA butno results are available so far.
The methodological quality of the literaturereviews was generally poor, and none of the reviews
Executive summary
iv
was systematic. Conclusions from nine reviews onanterior crowding suggested that there was only aweak association between retention of third molarsand crowding. Six out of 21 reviews with a moregeneral scope also concluded that the prophylacticremoval of third molars was unjustified. Twelvegeneral reviews did not conclude with a clearmessage about the management of third molars.Three reviews suggested that prophylactic removalof third molars is appropriate, but these reviewswere of poorer methodological quality than themajority of other reviews. Three out of four papersfocusing on surgical management expresseduncertain conclusions relating to the prophylacticextraction of third molars.
It is difficult to compare prophylactic removal ofimpacted third molars with retention in theabsence of disease, partly because these twostrategies are related to different types ofoutcomes. By using utility methods, four decisionanalyses made it possible to compare differentoutcomes directly in the coherent models.Although there were important differences in thestructure and methods for estimating input values,the findings of the decision analyses (by two
groups of researchers) consistently suggested thatretention of third molars was cost-saving and morecost-effective compared with prophylactic removalof impacted third molars.
Conclusions
There is no reliable research evidence to supportthe prophylactic removal of disease-free impactedthird molars. Available evidence suggests thatretention may be more effective and cost-effectivethan prophylactic removal, at least in the short tomedium term.
Recommendations for research1. Although data from observational studies may
be useful, there is a need for well-designed RCTsto compare prophylactic removal withmanagement by deliberate retention, usinglong-term follow-up.
2. There is also a need for decision analysis modelsthat could be used to compare long-termoutcomes of prophylactic removal with retentionof impacted third molars.
Executive summary
Health Technology Assessment 2000; Vol. 4: No. 15
1
Introduction
Removal of third molars (wisdom teeth) is one ofthe most common surgical procedures performedin the UK. In 1994–95 there were over 36,000 in-patient and 60,000 day-case admissions inEngland for ‘surgical removal of tooth’.1 Thirdmolar surgery has been estimated to cost the NHS in England up to £30 million per year,2 andapproximately £20 million is spent annually in theprivate sector.3 Around 90% of patients on waitinglists for oral and maxillofacial surgery arescheduled for third molar removal.3
There are wide variations in rates of third molarsurgery across the UK.2,4 There is some evidencethat deprived populations with poor dental healthare less likely to have third molars removedcompared with more affluent populations withgood dental health.2,5 However, the reasons for this are complex.
The proportion of third molar surgery which iscarried out prophylactically is difficult to estimateprecisely and depends on the definitions used.Some estimates of prophylactic removal suggestrates of between 20% and 40%,6–8 but rates as low as 4% have been reported.9 A UK survey of 181 consultants found that of 19,971 third molarsreferred to hospital for assessment, and sub-sequently removed, 43.9% were disease-free.10 Thissurvey also revealed that relatively more maxillarythird molars than mandibular third molars wereremoved prophylactically. The rate of disease-freeextracted teeth was 79.0% in 7735 maxillary thirdmolars and 21.8% in 12,236 mandibular thirdmolars.10
Little controversy surrounds the removal ofimpacted third molars when they are associatedwith pathological changes such as infection, non-restorable carious lesions, cysts, tumours, anddestruction of adjacent teeth and bone.11,12
However, the justification for prophylactic removalof impacted third molars is less certain and hasbeen debated for many years.
Several reasons are given for the early removal ofdisease-free impacted third molars: they have nouseful role in the mouth; they may increase the
risk of pathological changes and symptoms; if theyare removed only when pathological changesoccur, patients may be older and the risk of seriouspost-operative complications may be greater.
On the other hand, the probability of impactedthird molars causing pathological changes in thefuture may be exaggerated.3,13 Many impacted orunerupted third molars may eventually eruptnormally and many impacted third molars nevercause clinically important problems.14 In addition,third molar surgery is not risk-free. The com-plications and suffering following third molarsurgery may be considerable.15
Therefore, the decision to remove third molarsprophylactically should be based on an estimate of the balance between the likelihood of retainedthird molars causing problems in the future andthe risks or advantages of surgery carried outearlier compared with later. However, it is notpossible to predict reliably whether impacted thirdmolars will develop pathological changes if theyare not removed. Wide variation has been observedamong practitioners in their perceived risk offuture associated pathological changes and intreatment decisions in the management ofimpacted third molars.16–18
Impacted third molars
Impaction occurs where there is prevention ofcomplete eruption into a normal functionalposition of one tooth by another, due to lack ofspace (in the dental arch), obstruction by anothertooth, or development in an abnormal position.According to the definitions given by the Faculty of Dental Surgery of the Royal College of Surgeonsof England,12 a tooth that is completely impacted is entirely covered by soft tissue and partially orcompletely covered by bone within the mandible(lower jaw) or maxilla (upper jaw); partialeruption occurs when the tooth is visible in themouth but has failed to erupt into a normalfunctional position.
It should be noted that any normally erupted teethused to be unerupted and partially erupted atcertain stages of eruption process. Therefore,
Chapter 1
Background
Background
2
unerupted or partially erupted teeth may not be impacted.12
Pathological changes associatedwith impacted third molarsImpacted third molars may be associated withcertain pathological changes such as infections,dental caries, destruction of adjacent teeth, cystsand tumours. Although impacted third molars donot necessarily cause some of these pathologicalchanges (such as dental caries), the impaction mayincrease the risk of disease, particularly when oralhygiene is poor.
Pericoronitis (inflammation of the gingivasurrounding the crown of a tooth) is the mostcommon indication for third molar surgery,10
and mainly occurs in adolescents and young adults,and less commonly in older people.19 One studyreported that during 4 years of follow-up, 10% oflower third molars developed pericoronitis.20
Very few impacted third molars cause dental caries(decay) of second molars,19 though estimates ofthe rate vary (1% to 4.5%).15
There is a low incidence (less than 1%) of rootresorption of second molars with impacted thirdmolars.20,21 One review concluded that the risk ofsecond molar root resorption by impacted thirdmolars is low, and is likely to occur in youngerpatients for whom surgery is claimed to beassociated with lower morbidity.19
The association between anterior (front) incisorcrowding (predominantly a cosmetic problem) and impacted third molars is not significant and
is not considered to warrant the removal of third molars.22–24
Cyst development is very rare and is notconsidered to be an indication for prophylacticremoval.19 The risk of malignant neoplasms arising in a dental follicle is negligible and is not considered to be an indication for prophy-lactic removal.19
Complications and risks following surgeryThe potential benefit of avoiding the relativelyuncommon risks of pathological changesassociated with leaving impacted third molars inplace needs to be considered alongside the risksassociated with their removal.
Common complications following third molarsurgery include temporary or permanent sensorynerve damage (including anaesthesia andparaesthesia), dry socket (alveolar osteitis, or dry appearance of the exposed bone in thesocket), infection, haemorrhage and pain. Other possible complications include severetrismus (lockjaw), oro-antral fistula, buccal fat herniations, iatrogenic damage to the adjacent second molar, and iatrogenic mandibular fracture.
The rate of sensory nerve damage after third molarsurgery has been shown to range from 0.5% to20%.15,19,25,26 The reported overall rate of dry socketvaries from 0% to 35%.15,27 The risk of dry socketincreases with lack of surgical experience andtobacco use.28
Health Technology Assessment 2000; Vol. 4: No. 15
3
AimsThis review aims to provide a summary of existing evidence on prophylactic removal of impacted wisdom teeth, in terms of theincidence of surgical complications associated with prophylactic removal and the morbidityassociated with retention.
Methods
Selection criteria for studiesStudies were selected for inclusion if they met thefollowing criteria.
Study designEvaluations in the form of any relevant literaturereviews (published as a full paper) or randomisedcontrolled trials (RCTs) (published as a full paper,abstract, editorial, or letter) were considered forinclusion. Literature reviews could include bothRCTs or other studies designed to address long-term outcomes. Papers in all languages were considered.
ParticipantsStudies recruiting people with unerupted orimpacted third molars, and those undergoingsurgical removal of unerupted or impacted third molars, either as prophylaxis or because of pathological changes, were eligible forinclusion.
OutcomesReported outcomes had to include either thepathological changes and/or symptoms associatedwith unerupted or impacted third molars, or outcomes following surgical removal of third molars.
Search strategyAn existing review formed the basis of this report.23
Some additional searches of the following databaseswere carried out, with no language restrictions:
• MEDLINE (1984–99)• EMBASE (1984–99)• Science Citation Index (SCI) (via the BIDS
service)
• Cochrane Controlled Trials Register (CCTR)• National Research Register (NRR)• Database of Abstracts of Reviews of Effectiveness
(DARE)• NHS Economic Evaluation Database (NHSEED).
Paper sources searched included Clinical Evidence(BMJ Publishing Group). A search on thefollowing web-based resources was also carried out:
• Scottish Health Purchasing Information Centre(SHPIC) reports
• Scottish Intercollegiate Guidelines Network(SIGN) guidelines
• Agency for Health Care Policy and Research(AHCPR) clinical practice guidelines
• Guide to Clinical Preventive Guidelines,Development and Evaluation Committee (DEC)reports
• International Network of Agencies for HealthTechnology Assessment (INAHTA) publishedreports and ongoing reviews
• National Coordinating Centre for HealthTechnology Assessment (NCCHTA) reports
• Turning Research Into Practice (TRIP)• resources produced by the University of
Sheffield School of Health and RelatedResearch (ScHARR), including ‘Netting theEvidence’ and the Internet Database ofEvidence-Based Abstracts and Articles (IDEA) Topic List.
Other sources of information included The Facultyof Dental Surgery of the Royal College of Surgeonsof England and The British Dental Association,who provided additional information as submissionof evidence to the National Institute for ClinicalEvidence (NICE). In addition, SIGN supplied theNHS Centre for Reviews and Dissemination with adraft copy of their forthcoming guidelines on themanagement of third molars. The reference lists ofincluded articles were also checked to identifyrelevant studies.
The strategies used for searching MEDLINE,EMBASE, SCI, and CCTR are presented inappendix 1.
Decisions on the inclusion of studiesTitles and abstracts of studies identified by the
Chapter 2
Aims and methods
Aims and methods
4
searches were assessed for relevance by twoindependent reviewers. Any disagreements wereresolved by discussion, and failing this, by recourseto a third reviewer. Full papers were retrieved ifthey appeared to meet the inclusion criteria, or ifthere was doubt as to whether they were eligible.Screening of full papers was checked indepen-dently by two reviewers, and disagreements wereresolved as above.
Data extractionData were extracted into a structured table, andaccuracy was checked by a second, independent,reviewer. Discrepancies were resolved throughdiscussion. Different structured tables were used for reviews and RCTs. The data extracted from RCTs included study aims, method of randomisation,use of a priori power calculation, selection criteria for participants, baseline characteristics of groups,intervention details, numbers allocated to eachgroup, setting of treatment, outcome measurements,statistical methods, results per group for eachoutcome, follow-up, withdrawals, and author’s main conclusions. The data extracted from literature reviews included review aims, total number of references, and author’s mainconclusions.
For non-English papers, translators were recruitedto assist with study selection and data extraction. The data extraction summary tables are shown inappendix 2 (Tables 1 and 2) for RCTs, in appendix 3
(Table 3) for literature reviews, and in appendix 4(Table 4) for decision analysis studies.
Quality assessmentSelected articles were assessed by two reviewersindependently, with discrepancies resolved thoughdiscussion. For RCTs the following aspects wereassessed: participant selection criteria, sample size,reported use of a priori power calculation, methodof randomisation, baseline comparability of treat-ment groups, use of blinded outcome assessment,appropriate use of statistical methods for dataanalysis, reporting of withdrawals, and use of theintention-to-treat analysis. For literature reviews the following were evaluated: clarity of review aims,literature search, selection criteria, validityassessment, presentation of details of primarystudies, and methods of summarising data. Thesummary of validity assessment is shown in the dataextraction tables (Table 2, appendix 2 and Table 3,appendix 3).
Data poolingData from literature reviews were summariseddescriptively. Two RCTs were identified and thesewere not similar enough to allow for statisticalpooling (meta-analysis) of results. Therefore, these data were also combined descriptively. Some cost-effectiveness data were identified interms of the potential cost savings associated withreduced rates of prophylactic removal, which havebeen summarised as part of this report.
Health Technology Assessment 2000; Vol. 4: No. 15
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Included studiesThe search strategy detailed in chapter 2 generated 4682 references of possible relevance to this review. Once titles (and, when available, abstracts)had been assessed, hard copies of 290 papers were examined. Of these, 40 studies were included in this review: two RCTs,24,29 34 literaturereviews,4,13,15,19,22,30–59 and four decision analysisstudies.26,60–62 One of the literature reviews waspublished as two separate papers.51,52 Two paperspublished in French63,64 duplicated an Englishlanguage article, already included in this review.15
One paper published in Danish could not beretrieved.65
One RCT is a UK study,24 and the other, ongoing,trial is based in Denmark29 (appendix 2). Twelveliterature reviews were conducted in the USA, fourin Canada, four in the UK, four in Italy, three inFrance, two in Belgium, and one each in Hungary,Switzerland, Finland, Sweden, and South Africa(appendix 3). Two of the decision analysis studieswere conducted in the USA and two wereconducted in the UK (appendix 4).
Excluded studies
A further 29 studies were closely considered forinclusion but were eventually excluded from thereview.66–94 Common reasons for exclusionincluded study design, discussion of impacted teethother than third molars, or description of differentsurgical techniques or methods of treating post-operative complications. Details of excludedstudies are shown in appendix 5 (Table 5).
Results from RCTs
Harradine and colleagues (1998)24
This UK-based trial focused on the effects ofretained third molars on incisor crowding. Arandom number list was used to allocate par-ticipants to either extraction or retention of thirdmolars. All patients had previously undergoneorthodontic treatment. The mean age of entry tothe trial was 14 years 10 months, and 55% of thesample were female. In total, 164 patients entered
the trial, but only 77 (47%) were available for datacollection at the 5-year follow-up.
There were no statistically significant changes over time between the two groups in terms ofirregularity of dentition or intercanine width.There was, however, a small but statisticallysignificant difference in decrease in arch length,with a slightly smaller decrease in the group thatunderwent surgery. A similar pattern of results wasseen when some cases identified as having residualspacing from prior premolar extractions wereexcluded from the analysis. Generalised linearmodelling showed that there were no statisticallysignificant differences between those completingthe study and those who were lost to follow-up.
Overall the trial was well conducted. However,there was no reported power calculation forsample size, and so the power of the study to detecttrue treatment effects is uncertain. In addition,there are few data relating to baselinecharacteristics of participants according totreatment arm.
Vondeling and colleagues (1999)29
This trial in Denmark is ongoing, and aims to assessthe cost-effectiveness and clinical effectiveness ofthe prophylactic removal of third molars comparedwith extraction carried out according to associatedmorbidity. The method of randomisation was notdescribed, but participants were allocatedaccording to a blocked and stratified scheme. Onlybrief selection criteria were given, namely thatparticipants had to be healthy, aged between 18and 30 years, and to have at least one mandibularthird molar remaining. No information was givenabout baseline characteristics of study groups. Sofar, 200 participants have been recruited, but thisfigure was not broken down by group. It isanticipated that by the end of the trial 500participants will be recruited, 100 of whom willundergo prophylactic extraction. Only descriptiveresults were provided, and these suggested thatprophylactic removal of third molars may beassociated with decreased functional health status,increased healthcare costs and production losses,and that few patients in the watchful waiting grouphave developed pathological changes that wouldwarrant removal of third molars. The authors
Chapter 3
Results
Results
6
cautiously suggest that watchful waiting may be themore favourable strategy, but further results areawaited with interest.
Results from literature reviews
Thirty-four published literature reviews were ident-ified which fulfilled inclusion criteria for the reviewreported here. Data extraction summary tables arepresented in appendix 3 (Table 3). Twenty-one ofthe assessed reviews covered general issues aboutthe appropriateness of prophylactic removal ofimpacted third molars.4,13,15,19,30,31,35,39–41,44,46,48,50–52,54–59
Nine reviews focused on the association ofcrowding with third molars,22,32–34,38,42,43,49,53 and fourreviews were concerned with complicationsfollowing third molar surgery, namely, periodontaldefect,45 and sensory nerve damage.36,37,47
Methodological quality of thereviewsThe methodological quality of the literaturereviews was generally poor, and none could bedescribed as systematic. Details of study qualityassessment are shown with data extraction inappendix 3 (Table 3). With one exception,4 none ofthe reviews gave details of using a structured searchstrategy to identify primary material or selectioncriteria for studies. The details of individual studiesquoted in these literature reviews were usuallyinsufficient for readers to judge the reliability ofthe evidence provided. Several reviews includedvery brief comments on the methodological qualityof primary studies,4,13,15,22,39,40,51,52 but nonedescribed a systematic assessment of validity. The literature included in these reviews includedreviews and case reports as well as reports ofstudies that used a range of methodologies,including retrospective or prospective, cross-sectional or longitudinal observational studies. No RCTs comparing the long-term outcome ofearly removal with that of deliberate retention of disease-free third molars were identified. These literature reviews seldom quantitativelysummarised the risk of removal or retention ofimpacted third molars.
Conclusions from reviewsEight out of nine reviews on anterior crowdingconcluded that prophylactic removal of thirdmolars for the prevention of crowding of loweranteriors was not justified.22,32–34,42,43,49,53 The otherreview38 recommended prophylactic removal ofthird molars, but review methods were very poor,and only nine references were cited overall.The conclusions from 12 of the 21 general reviews
were uncertain and no clear answer was givenabout the appropriateness of prophylactic removalof impacted third molars.15,30,31,35,39,40,48,50,55,57–59 Six ofthe general reviews concluded that prophylacticremoval of impacted third molars wasunjustified.4,13,19,41,51,52,56 Three reviews44,46,54
recommended the prophylactic removal of thirdmolars but the methods used in each of thesereviews were poorer than for many other reviewswith different conclusions (appendix 3). Out offour papers focusing on surgical complications,three expressed uncertain conclusions,37,45,47 andone was in favour of prophylactic removal.36
Decision analyses for third molarsurgeryThe appropriateness of prophylactic removal ofimpacted third molars should be evaluated bycomparing the outcomes of prophylactic removalwith the outcomes of retaining teeth. Onedifficulty in the comparison of the two strategies isin valuing and comparing the various outcomes.The outcome of surgical removal of impacted thirdmolars is measured by the rate of variouscomplications. On the other hand, the conseq-uences of deliberate retention of impacted thirdmolars in the absence of associated morbidity willinclude the incidence of different pathologicalchanges and the rate of complications followingdelayed surgical removal.
To be directly comparable, the outcomes of the twostrategies need to be summarised by a commonmethod. This problem has been addressed inseveral decision analyses.26,60–62 For example, ‘daysof standard discomfort’ (DSD) was used as a singleunit outcome measure to estimate extractionoutcome in a decision analysis by Tulloch andAntczak-Bouckoms.61 In another study, the outcomewas measured by a utility value that “represents acondensation of the biological, physical,sociological, and psychological parameters thatinfluence a person’s sense of well-being”.26
The major features and findings from the fouridentified decision analyses that compared differentstrategies for managing third molars are shown inappendix 4 (Table 4). A decision analysis by ECRI(an independent nonprofit health services researchagency) has been included in Table 4 but will not bediscussed in detail here because it considered onlyeconomic consequences after different strategies.39
The ECRI study concluded that there are noreliable predictors of pathological changes anddisease and that although prophylactic removal of
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third molars decreases the likelihood of futurepathological changes and post-operativecomplications, it does not alleviate anterior dentalarch crowding. Surgery may benefit only one in sixpatients, and the procedure may be associated withpotential risks from post-operative complications,such as nerve damage.
Tulloch and Antczak-Bouckoms (1987)61
Three strategies of the management of lower thirdmolars were evaluated by Tulloch and Antczak-Bouckoms:61
• removing all disease-free third molars beforetheir complete root formation
• removing only those teeth that remainimpacted
• removing only those impacted teeth that hadassociated pathology.
The probabilities of complications associated withremoval (pain, swelling, bruising, and malaise)were subjectively estimated by nine surgeons. The DSD associated with various complicationswere estimated by 46 clinicians. The results suggestthat “the strategy of removing only pathologicallyinvolved impacted third molars is generally therisk-minimising option”.
This decision analysis considered the expecteddisability following surgical removal of third molarsbut did not consider disability associated withpathological changes of retained third molars. The findings of this study may be questionablebecause the estimated values of input parameters(utility and probabilities) were based on thesubjective judgements of clinicians, or were basedon poor quality literature. However, the authorsused sensitivity analysis to test a wide range ofassumptions and found that the model is sensitiveto the severity of the outcome “when these valuesbecome rather extreme”.
Tulloch and colleagues (1990)62
The decision analysis carried out by Tulloch andcolleagues62 was similar to the analysis by Tullochand Antczak-Bouckoms61 in terms of the structureand estimates of input parameters. However, it also included the costs of different strategies.Clinicians’ reported fees and patient records wereused to estimate the cost of the surgical procedure,and the cost (1985 US dollars) of treating anypathological changes associated with third molarsor complications of surgery.
The results of this analysis suggested that theoptimal strategy was to remove only impacted third
molars with pathological changes. This strategy wasassociated with the lowest expected disability andalso the lowest expected cost. Estimations of DSDwere 2.27, 0.67, and 0.33 for all early removals,removal of impacted disease-free teeth, andremoval of impacted teeth with disease,respectively. The central estimates of costs,presented as the cost per person if that strategywere universally adopted, were $247 for all earlyextractions, $66 for extractions of impacted teethonly, and $46 for extractions of impacted teethwith pathology. These findings maintained asimilar pattern under best- and worst-casescenarios. Here the best-case scenario was “underthe assumptions of least severe impactions, lowestchance of pathology, and lowest disability and costassociated with the outcome”. The worst-casescenario was “the most severe impaction type, thegreatest chance of pathology, and the highestestimates of disability and cost”.
Brickley and colleagues (1995)26
In the analysis by Brickley and colleagues,26 patient-derived utility values were used to measurepatients’ well-being following one of two strategiesfor the management of lower third molars: (1)removing all impacted third molars; (2) nointervention or conservative treatment. Theestimated probabilities of outcomes were based ona literature review15 and data from an audit,conducted by the authors, of 300 consecutivepatients with third molar problems. The resultsshowed that the maximum expected utility of non-extraction (76.96) was better than that forprophylactic third molar surgery (60.25). Results ofa sensitivity analysis suggest that the outcome ofnon-extraction will be better than that ofprophylactic third molar surgery unless the risk ofdisease with no extraction, relative to the riskshown by the clinical audit and literature review, is:
• 52% higher for pericoronitis• 29% higher for resorption of an adjacent tooth• 32% higher for loss of the adjacent tooth due
to caries• 43% higher for anterior incisor crowding• 34% higher for cystic change.
Edwards and collegues (1999)60
The decision analysis by Edwards and colleagues60
was similar to that by Brickley and colleagues,26
using the same structure (decision tree) and asimilar approach for estimating utility values andprobabilities of outcomes. This decision analysisestimated and compared cost and cost-effectivenessof different strategies. In addition, the probabilitiesof various outcomes were estimated by an up-dated
Results
8
literature review (1966–98), and the values ofutility were estimated by patients who attended the oral surgery clinic at the University of WalesDental Hospital.
The average NHS cost was estimated as £170 formandibular third molar retention, and £226 forsurgical extraction, resulting in a marginal cost of–£56. The effectiveness of mandibular third molarmanagement was rated as being greater for thirdmolar retention (69.5) compared with surgicalremoval (63.3), giving a marginal effectiveness of6.2. The incremental ratio of cost to effectivenessfor retention compared with removal was thereforenegative (–£56/6.2 = –£9.03 per extra unit ofeffectiveness). That is, mandibular third molarretention was less costly and more effective thanprophylactic removal of disease-free third molars.
A sensitivity analysis indicated that this finding was sensitive to changes in the probability ofpericoronitis, periodontal disease and caries. The most cost-effective strategy would alter fromretention to removal if the probability ofpericoronitis increased from 22% to 40%, theprobability of periodontal disease increased from5% to 17%, or the probability of unrestorable cariesin the second molar increased from 10% to 22%.
Are the results of the decision analyses valid?The validity of these decision analyses should beexamined to decide whether their findings arebelievable. According to guidelines about usingclinical decision analysis, the following questionsneed to be addressed:95
• were all important strategies and outcomesincluded?
• was an explicit and sensible process used toidentify, select, and combine the evidence intoprobabilities?
• were the utilities obtained in an explicit andsensible way from credible sources?
• was the potential impact of any uncertainty inthe evidence determined?
Were all important strategies and outcomesincluded?The strategies compared in these decision analysesseem appropriate. Prophylactic removal ofimpacted third molars was compared withretention of disease-free third molars. In theanalyses by Tulloch and colleagues61,62 onlycomplications following removal of third molarswere considered. The outcomes of retention andremoval of impacted third molars were included in
the studies by Brickley and colleagues26 and byEdwards and colleagues.60 Decision analyses byTulloch and colleagues62 and by Edwards andcolleagues60 included the costs of differentstrategies.
Was an explicit and sensible process used to identify, select and combine the evidence into probabilities?The probabilities of various outcomes wereestimated by using subjective judgement ofclinicians,61 an audit of patients with third molarproblems,26 and literature reviews.26,60–62 Althoughthe process was explicitly described and seeminglysensible, details were often not available in thepublished decision analyses.
The risk of pathological changes associated withthird molars may have been overestimated in thedecision analyses when the proportions of patientswith symptomatic impacted third molars were usedto estimate the incidence of pathological changesamong the total population with impacted thirdmolars. On the other hand, probabilities ofcomplications following third molar surgery wereestimated by including patients undergoingprophylactic and non-prophylactic third molar surgery.
Were the utilities obtained in an explicit andsensible way from credible sources?The methods used to obtain utility values wereexplicitly described in these decision analyses. Thevalues of utilities were estimated by clinicians inone study by Tulloch and Antczak-Bouckoms,61 andby patients in the decision analyses by Brickley andcolleagues (1995).26 The patient-derived utilityused in the decision analyses by Brickley andcolleagues26 and Edwards and colleagues60 seemsmore relevant and appropriate than the clinician-estimated utilities used in other studies.
Was the potential impact of any uncertainty inthe evidence determined?The potential impact of uncertainty in theevidence was tested by sensitivity analyses in allfour decision analyses. According to the results ofsensitivity analyses, findings were quite robust. Theconclusions will alter only when the severity of theoutcome or the probability of some diseasechanges considerably.
Time horizonPerhaps the major weakness of these decisionanalyses is that they were not able to consider the impact of time span on the outcomes. Theoutcomes following surgical removal of third
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molars occur early and are mainly short-termevents (except permanent sensory nerve damage or other rare complications), whereas the outcomes associated with retention of disease-free third molars may occur in later life and canonly be fully measured with a long-term follow-up.Patients’ time preference and the impact of long-term outcomes may not have been fully incorp-orated into the decision analyses.
The cumulative probabilities of various pathologicalchanges associated with impacted third molars mayincrease with a longer duration of follow-up,shifting the model more towards favouringextraction. On the other hand, the advantages ofretention of disease-free third molars may beenhanced because of the effect of discounting thecosts and/or disability which might be expected tooccur at a more distant time, shifting the modelmore towards favouring retention.62
The usefulness of conventional decision analysisis limited when it is used to study clinical decisionsthat have long-term implications. When probabilityand utility variables change over time, Markovprocess analysis can be used but the modellingbecomes much more complicated.96 Markovmodelling has been used, for example, to simulatethe eruption of lower third molars.97 A morecomplex Markov model may be helpful to explorelong-term outcomes of prophylactic removalcompared with retention of impacted third molars.
Summary of decision analysesAlthough there were important differences in the structure and methods for estimating inputvalues, the findings of the decision analyses (by two groups of researchers) consistently indicatedthat patients’ well-being is maximised if surgicalremoval is confined to impacted third molars withpathological changes. Retention was the most cost-saving and cost-effective strategy comparedwith prophylactic removal of all impacted third molars.60,62
These decision analyses made it possible tocompare different outcomes directly in thecoherent models. The utility values andprobabilities of various outcomes were explicitlypresented. The uncertainty of input values wastested. Since there are no controlled studiescomparing long-term outcomes of retention withoutcomes of prophylactic removal of impactedthird molars, the recommendations provided
by the decision analyses may be relevant andimportant in relation to decision-making for themanagement of impacted third molars. Havingsaid that, it should be stressed that these decisionanalyses were mainly based on research evidencefrom primary studies that had a poor quality of design.
Cost and cost-effectivenessanalysis of prophylactic removal of third molars
According to data reported in Extraction of wisdomteeth: submission of evidence to NICE (by the Faculty of Dental Surgery of The Royal College ofSurgeons of England), in 1995–96 the totalnumber of third molar teeth removed was 121,577(upper 42,578; lower 78,999), at a total cost of£11.8 million to the NHS General Dental Services(England & Wales).98 Therefore, the average costper third molar removed can be estimated as£97.06. According to the initial report of the UKNational Third Molar project,10 43.9% of the thirdmolars removed in 1995 were disease-free.Therefore it is possible to estimate that the totalnumber of third molars removed prophylacticallyin 1995–96 was about 53,372 each year in the NHSGeneral Dental Services (England & Wales) with atotal cost of about £5.2 million. This estimated costshould be interpreted with caution. It is possiblethat the data reported are inaccurate, and detailsabout cost are not available. In addition, theFaculty of Dental Surgery of the Royal College ofSurgeons of England suggests that current rates ofprophylactic removal are about 4%, much lowerthan the previous estimates. However, this needs tobe confirmed.
The decision analysis by Edwards and colleaguesestimated cost-effectiveness of removal andretention of disease-free third molars.60 The cost to the NHS included consumables, staff costs, and overheads. The average cost (not discounted)of the prophylactic removal of an impactedmandibular third molar was about 33% higherthan the cost of retention (£226 compared with £170).
The compensation awarded for permanent nervedamage after third molar surgery ranges from£5000 to £14,000 per case or higher.99
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Quality of available evidenceThe appropriateness of prophylactic removal of impacted third molars should be evaluated bycomparing the outcomes of prophylactic removalwith the outcomes of retention. One difficulty inthe comparison of the two strategies lies in valuing and comparing the various outcomes. The outcomes of surgical removal of impactedthird molars are assessed by the rate of variouscomplications. On the other hand, theconsequences of deliberate retention of impactedthird molars without disease will include theincidence of different pathological changes andthe rate of complications following delayed surgical removal. To be directly comparable, theoutcomes of the two strategies need to besummarised by a common method, for exampleDSD or utilities.
RCTsOne RCT examined the effects of early extractionof third molars on late lower incisor crowding.24
It concluded that the removal of third molars toreduce or prevent late incisor crowding cannot bejustified. The preliminary results reported in anabstract describing another RCT, which aims tocompare the effects and costs of prophylactic thirdmolar removal with those of removal according tomorbidity, suggested that watchful waiting may be a promising strategy but acknowledged that moredata and longer follow-up of patients are neededto identify the most cost-effective strategy.29
Additionally, a prospective multi-centre RCT hasbeen commissioned in the USA, and results areawaited with interest. This RCT aims to compareremoval with retention of third molars in terms of clinical, biological, and health-related quality of life outcomes. It is planned to compare theseoutcomes across patient groups stratified by age,gender, and race.98
Literature reviewsThe general quality of the literature reviewsidentified is quite poor. Since authors did notexplicitly describe review methods such as thesearch strategy and criteria for inclusion ofindividual studies, they might have selectivelyincluded those studies that supported their ownopinion. The total number of references used in
these literature reviews ranges from nine to 149. Inour 1996 review of 12 literature reviews ofimpacted third molars we found that reviews withsimilar aims included different sets of studies asevidence from which to draw conclusions.23 Forexample, 69 studies were quoted overall in ninegeneral reviews to discuss the association betweendisease and third molars. None of these 69references was used by more than five literaturereviews. One study was quoted in five reviews,whereas 43 studies were included in only onereview. This discrepancy in the use of relevantstudies cannot be explained by the year ofpublication or by any other acceptable reason.
The identified literature reviews included primarystudies with various designs such as retrospective orprospective observational studies and case reports.The relevance and quality of primary studies wasinadequately assessed in the majority of cases.Sufficient details of the included primary studieswere not presented and the interpretation ofprimary studies may not be valid. For example,some reviews used the proportion of patientsundergoing third molar surgery to estimate theincidence of disease among populations. Thisapproach may overestimate incidence considerably.In addition, when the incidence was reported, theduration of follow-up was sometimes unclear in thereviews. Since the quality of studies was not appro-priately assessed, and sufficient details of studieswere not presented, it is difficult to distinguish poorquality data from more reliable evidence providedin these reviews.
These literature reviews seldom quantitativelysummarised the risk associated with removal orretention of impacted third molars. It is difficult to draw a balanced conclusion about the appro-priateness of prophylactic third molar removal,partly because of the different outcomes ofretention and removal that are used. Consideringthe complexity of the relevant issues and a lack ofgood objective evidence, it is perhaps unsurprisingthat the majority of reviews provide uncertainrecommendations. However, it appears thatliterature reviews which conclude that prophylacticremoval is inappropriate are of bettermethodological quality than many other reviews(appendix 3).
Chapter 4
Discussion and conclusions
Discussion and conclusions
12
Decision analysesSeveral decision analyses made it possible tocompare different outcomes directly in thecoherent models. The utility values andprobabilities of various outcomes were explicitlypresented. The uncertainty of input values wastested. Since there are no controlled studiescomparing long-term outcomes of retention and outcomes of prophylactic removal of impactedthird molars, the recommendations provided by thedecision analyses may be relevant to the decision-making process relating to the management ofimpacted third molars. However, it should bestressed that these decision analyses were mainlybased on research evidence from primary studiesthat were of poor design quality.
Although there were important differences in the structure and methods for estimating inputvalues, the findings of the decision analyses (by two groups of researchers) consistentlyindicated that patients’ wellbeing is maximised if surgical removal is confined to those impactedthird molars associated with pathological changes.Retention was the most cost-saving and cost-effective strategy compared with prophylacticremoval of all impacted third molars.60,62
Conclusions
There is no reliable research evidence to supportthe prophylactic removal of disease-free impactedthird molars. Available evidence suggests thatretention may be more effective and cost-effectivethan prophylactic removal, at least in the short tomedium term.
The results of two ongoing RCTs, one based inDenmark29 and one in the USA, are awaited with interest.
Recommendations for research1. Although data from observational studies may
be useful, there is a need for well-designedRCTs to compare prophylactic removal withmanagement by deliberate retention, usinglong-term follow-up.
2. There is also a need for decision analysismodels that could be used to compare longterm outcomes of prophylactic removal withretention of impacted third molars.
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The project team would like to thank TheFaculty of Dental Surgery of the Royal College
of Surgeons of England and The British DentalAssociation, for providing additional informationas submission of evidence to NICE. We would alsolike to thank the Scottish Intercollegiate Guide-lines Network for providing us with a draft copy of their forthcoming guidelines.
We are indebted to the referees for theirperseverance in reading the report and the quality of their comments.
The views expressed in this report are those of theauthors, who are also responsible for any errors.
Acknowledgements
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75. Garattini G, Piccoli P, Sacilotto GL, Carrassi A. Lagermectomia dei terzi molari inferiori: tecnichechirurgiche e criteri di scelta. Mondo Ortodont1988;13:61–6.
76. Kalamchi S, Hensher R. The management ofimpacted mandibular third molars 2. Treatment.Dent Update 1987;14: 437–40.
77. Klein C, Lorber CG. Die entwicklung deroperativen weisheitszahnentfernung. Fortschr KieferGesichtschir 1995;40:113–6.
78. Ko K, Dover D, Jordan R. Bilateral dentigerous cysts– report of an unusual case and review of theliterature. J Can Dent Assoc 1999;65:49–51.
79. Koerner K. The removal of impacted third molars.Principles and procedures. Dent Clin North Am1994;38:255–78.
80. Kokich V, Matthews D. Surgical and orthodonticmanagement of impacted teeth. Dent Clin North Am1993;37:181–204.
81. Leonard MS. Removing third molars: a review forthe general practitioner. J Am Dent Assoc1992;123:77–86.
82. Lytle J. Etiology and indications for themanagement of impacted teeth. Northwest Dent1995;74:23–32.
83. MacGregor A. Reduction in morbidity in thesurgery of the third molar removal. Dent Update1990;17:411–14.
84. Pajarola GF, Jaquiéry C, Lambrecht TJ, Sailer HF.Extraction chirurgicale des dents de sagesseinferieures (II). Technique operatoire, soinspostoperatoires, complications. Rev Mensuelle SuisseOdontostomatol 1994;104:1521–34.
85. Richardson ME. The role of the third molar in thecause of late lower arch crowding: a review. Am JOrthodont Dentofac Orthop 1989;95:79–83.
86. Sentilhes C. Indications des germectomies desdents de sagesse. Rev Odontostomatol1988;17:199–209.
87. Seward GR, Harris M, McGowan DA. Uneruptedand impacted teeth. In: Killey and Kay’s outline oforal surgery, part one. Bristol: Wright; 1984. p. 52–91.
88. Stamatis J, Orton H. The molar extraction debate.Aust Orthodont J 1994;13:117–21.
89. Stavisky E. Clinical justification for the prophylacticremoval of impacted third molars. Pa Dent J1989;56:8–9.
90. Taft L, Prigoff W. To extract or not to extract thirdmolars. NY State Dent J 1987;53:36–8.
91. Turcotte JY, Saucier J, St-Hilaire P. Les troisiemesmolaires incluses: extraire ou conserver? J Dent Que1987;24:115–19.
92. Turcotte JY. L’alveolite, qu’en est-il aujourd’hui? JCan Dent Assoc 1997;63:206–10.
93. Windecker D, Kendzia G. Der weisheitszahn ausprothetischer sicht. Dtsch Zahnarztl Z1986;41:119–26.
94. Yamada N, Takarada H, Kudo I, Tomioka T. To what extent can we keep our own teeth?Indications for extraction [Japanese]. Nippon ShikaIshikai Zasshi 1985;37:1153–8.
95. Richardson W, Detsky A. Users’ guides to themedical literature VII. How to use a clinicaldecision analysis A. Are the results of the studyvalid? JAMA 1995;273:1292–5.
96. Naimark D, Krahn MD, Naglie G, Redelmeier DA,Detsky AS. Primer on medical decision analysis: part5 – working with Markov process. Med Decis Making 1997;17:152–9.
97. Brickley MR, Shepherd JP. A study of the validity ofa simulation of third molar eruption based onMarkov modelling. Br Dent J 1998;185:233–7.
98. Faculty of Dental Surgery. Extraction of wisdomteeth: health technology appraisal. Submission ofevidence to NICE. London: The Royal College ofSurgeons of England; 1999.
99. Walters H. Reducing lingual nerve damage in thirdmolar surgery: a clinical audit of 1350 cases. Br DentJ 1995;178:140–4.
MEDLINE search strategy(1984–99)1. molar third/ep,su,th,pc2. molar third/3. tooth impacted/4. (third adj molar$).ti,ab,sh.5. (wisdom adj (teeth or tooth)).ti,ab,sh.6. (itm or itms).tw.7. or/2-68. animal/9. human/10. 8 not (8 and 9)11. 7 not 10
EMBASE search strategy(1984–99)1. “molar-tooth”/epidemiology, prevention,
surgery, therapy2. “molar-tooth”/all subheadings3. (third near1 molar*) in ti ab4. (wisdom near1 (teeth or tooth)) in ti ab
5. (itm or itms) in ti ab6. #1 or #2 or #3 or #4 or #57. nonhuman8. explode “human”/all subheadings9. #7 not (#7 and #8)10. #6 not #911. #10 and (PY > “1983”)
Science Citation Index (via BIDS) search strategySearch: (wisdom teeth)@TKA,(wisdom
tooth)@TKA,(third molar*)@TKA,(molar
teeth)@TKA,(itm or itms)@TKA
CCTR search strategy1. MOLAR-THIRD*:ME2. (THIRD near MOLAR*)3. (WISDOM near (TOOTH or TEETH))4. ((#1 or #2) or #3)
Health Technology Assessment 2000; Vol. 4: No. 15
19
Appendix 1
Search strategies
Health Technology Assessment 2000; Vol. 4: No. 15
21
Appendix 2
Summary of data extraction and quality assessment of RCTs
Appendix 2
22 TAB
LE 1
D
ata
extra
ctio
n of
RCT
s
Ref
eren
ce,c
oun
try,
Par
tici
pant
sel
ecti
on
crit
eria
In
terv
enti
on
Res
ults
Wit
hdra
wal
sA
utho
rs’ c
onc
lusi
ons
and
ai
m,d
esig
n de
tails
and
base
line
char
acte
rist
ics
deta
ilsre
view
ers’
co
mm
ents
Har
radi
ne,e
t al
.,19
9824
Incl
usio
n cr
iteria
Gro
up 1
Stat
istica
l tec
hniq
ues
Ove
rall
77 p
atie
nts
Auth
ors’
conc
lusio
ns(1
) Pa
tient
s w
ho h
ad p
revi
ousl
yEx
trac
tion
of t
hird
tte
sts,
asso
ciat
ed(4
7%)
com
plet
ed t
heT
he r
emov
al o
f thi
rd m
olar
sU
Kun
derg
one
orth
odon
tic t
reat
men
t,bu
t m
olar
s (n
= 4
4)co
nfid
ence
inte
rval
s (C
Is)
tria
l,of
who
m 4
5to
red
uce
or p
reve
nt la
tew
ere
no lo
nger
wea
ring
any
ort
hodo
ntic
M
ean
±SD
cha
nge
in L
II(5
8%)
wer
e fe
mal
esin
ciso
r cr
owdi
ng c
anno
tRe
sear
ch a
imap
plia
nces
or
reta
iner
s on
ent
ry t
o th
e G
roup
2G
roup
1:0
.80
±1.
23 m
mbe
just
ified
To a
sses
s th
e ef
fect
s of
ear
lyst
udy.
Ort
hodo
ntic
tre
atm
ent
com
pris
ed
Ret
entio
n of
thi
rd
Gro
up 2
:1.1
0 ±
2.72
mm
Gen
eral
ised
line
arex
trac
tion
of t
hird
mol
ars
on
activ
e tr
eatm
ent
in t
he u
pper
arc
h on
ly
mol
ars
(n=
33)
(p=
0.5
5)m
odel
ling
late
low
er in
ciso
r cr
owdi
ngw
ith e
ither
rem
ovab
le a
pplia
nces
or
a M
ean
±SD
cha
nge
in IC
Wde
mon
stra
ted
noRe
view
ers’
com
men
tsM
etho
d of
ran
dom
isatio
nsi
ngle
arc
h fix
ed a
pplia
nce,
with
no
Se
tting
of t
reat
men
tG
roup
1:–
0.37
±0.
73 m
msy
stem
atic
diff
eren
ces
Lim
itatio
ns o
f the
stu
dy:
Ran
dom
num
ber
list
trea
tmen
t or
pre
mol
ar e
xtra
ctio
ns o
nly
Br
isto
l Den
tal H
ospi
tal
Gro
up 2
:0.3
8 ±
0.85
mm
betw
een
thos
e ov
eral
l,th
is is
a w
ell-
Sam
ple
size
calcu
latio
nbe
ing
carr
ied
out
in t
he lo
wer
arc
h.(p
= 0
.92)
patie
nts
who
co
nduc
ted
tria
l.M
uch
of
Non
e re
port
ed(2
) All
patie
nts
had
crow
ded
thir
d m
olar
s M
ean
±SD
cha
nge
in A
Lco
mpl
eted
the
stu
dy,
the
anal
ysis
focu
ses
on
Out
com
e m
easu
rem
ents
(i.e.
thir
d m
olar
s fo
r w
hich
the
long
axi
s,G
roup
1:–
1.1
±1.
13an
d th
ose
who
diffe
renc
es b
etw
een
(1
) Li
ttle
’s Ir
regu
lari
ty In
dex
(LII)
and
ther
efor
e pr
esum
ed p
ath
of e
rupt
ion,
Gro
up 2
:–2.
13 ±
0.97
wer
e lo
st t
oco
mpl
eter
s an
d th
ose
who
(2
) In
terc
anin
e w
idth
(IC
W)
was
thr
ough
the
adj
acen
t se
cond
mol
ar)
(p=
0.0
01)
follo
w-u
pw
ere
lost
to
follo
w-u
p.(3
) Arc
h le
ngth
(A
L)Ex
clus
ion
crite
riaA
sim
ilar
patt
ern
of r
esul
ts
Mor
e de
tails
abo
utT
he a
bove
mea
sure
men
ts w
ere
Res
idua
l pre
mol
ar e
xtra
ctio
n sp
ace
was
foun
d w
hen
case
s w
ith
com
para
bilit
y of
stu
dyre
cord
ed a
t ba
selin
e an
d fo
llow
-Ba
selin
e ch
arac
teris
tics
resi
dual
spa
ce fr
om
arm
s at
bas
elin
e w
ould
up,
and
diffe
renc
es b
etw
een
the
Rep
orte
d fo
r ov
eral
l sam
ple,
and
not
prem
olar
ext
ract
ion
on
have
bee
n us
eful
2 tim
e-po
ints
wer
e ca
lcul
ated
per
stud
y gr
oup
tria
l ent
ry w
ere
excl
uded
Leng
th o
f fol
low
-up
Age
of e
ntry
to
the
tria
l (m
ean
±SD
):St
ated
min
imum
was
5 y
ears
.14
yea
rs 1
0 m
onth
s ±
16.2
mon
ths
Dat
a fo
r th
e up
per
arch
A
ctua
l mea
n ±
SD w
as
Gen
der:
M,n
= 7
4 (4
5%);
F,n
= 9
0 (5
5%)
show
ed n
o st
atis
tical
ly
66 ±
12.6
mon
ths
sign
ifica
nt d
iffer
ence
s be
twee
n th
e 2
grou
ps fo
ran
y m
easu
rem
ent
AL =
arc
h le
ngth
,CI =
con
fiden
ce in
terv
al,L
II =
Litt
le’s
Irreg
ular
ity In
dex,
ICW
= in
terc
anin
e w
idth
,SD
= s
tand
ard
devia
tion
cont
inue
d
Health Technology Assessment 2000; Vol. 4: No. 15
23TAB
LE 1
con
td
Dat
a ex
tract
ion
of R
CTs
Ref
eren
ce,c
oun
try,
Par
tici
pant
sel
ecti
on
crit
eria
In
terv
enti
on
Res
ults
Wit
hdra
wal
sA
utho
rs’ c
onc
lusi
ons
and
ai
m,d
esig
n de
tails
and
base
line
char
acte
rist
ics
deta
ilsre
view
ers’
co
mm
ents
Vond
elin
g,et
al.,
1999
29In
clus
ion
crite
riaG
roup
1Pr
ophy
lact
ic r
emov
al o
f N
o in
form
atio
nAu
thor
s’co
nclu
sions
Hea
lthy
part
icip
ants
age
d 18
–30
Prop
hyla
ctic
rem
oval
thir
d m
olar
s is
ass
ocia
ted
supp
lied
Wat
chfu
l wai
ting
may
Den
mar
kye
ars,
with
at
leas
t on
e
of t
hird
mol
ars
with
dec
reas
ed fu
nctio
nal
be a
pro
mis
ing
stra
tegy
.m
andi
bula
r th
ird
mol
arhe
alth
sta
tus
for
abou
tM
ore
data
and
long
erRe
sear
ch a
imEx
clus
ion
crite
riaG
roup
2a
wee
k,co
nsid
erab
le
follo
w-u
p of
pat
ient
sTo
com
pare
the
effe
cts
and
Non
e st
ated
T
hird
mol
ars
rem
oved
heal
thca
re c
osts
,and
ar
e ne
eded
to
conc
lude
cost
s of
pro
phyl
actic
rem
oval
Ba
selin
e ch
arac
teris
tics
acco
rdin
g to
mor
bidi
typr
oduc
tion
loss
es in
the
whi
ch t
reat
men
tof
thi
rd m
olar
s ve
rsus
rem
oval
No
info
rmat
ion
repo
rted
maj
ority
of p
atie
nts.
stra
tegy
is t
he m
ost
acco
rdin
g to
mor
bidi
tyO
vera
ll n
= 2
00So
far,
very
few
pat
ient
sco
st-e
ffect
ive
Met
hod
of r
ando
misa
tion
at t
his
stag
e in
the
wat
chfu
l wai
ting
Revie
wer
s’co
mm
ents
Not
sta
ted;
bloc
ked
and
stra
tifie
d(s
tudy
ong
oing
)gr
oup
have
dev
elop
edLi
mita
tions
of t
he s
tudy
:al
loca
tion
used
an in
dica
tion
for
rem
oval
data
are
tak
en fr
omSa
mpl
e siz
e ca
lcula
tion
The
ant
icip
ated
gro
up
abst
ract
.The
se a
reN
one
repo
rted
size
s fo
r th
epr
elim
inar
y re
sults
onl
y,O
utco
me
mea
sure
men
tsco
mpl
eted
stu
dy a
re:
and
the
stud
y is
ong
oing
Clin
ical
effe
ctiv
enes
s an
d qu
ality
Gro
up 1
,n=
100
of li
fe,u
sing
gen
eric
que
stio
nnai
res
Gro
up 2
,n=
400
Econ
omic
eva
luat
ion,
appl
ying
a
soci
etal
per
spec
tive
Leng
th o
f fol
low
-up
6 ye
ars
(Gro
up 2
)
Appendix 2
24 TAB
LE 2
M
etho
dolo
gica
l ass
essm
ent
of R
CTs
Ref
eren
ce,
Cle
ar in
clus
ion
Ove
rall
sam
ple
A p
rior
iM
etho
d o
fC
om
para
bilit
yB
linde
dA
ppro
pria
teW
ithd
raw
als
Inte
ntio
n to
loca
tio
nan
d ex
clus
ion
size
(nu
mbe
r o
fsa
mpl
e si
zera
ndo
mis
atio
no
f gr
oup
so
utco
me
met
hods
use
d tr
eat
anal
ysis
?cr
iter
ia?
arm
s)ca
lcul
atio
n?re
port
ed a
tas
sess
men
t?fo
r st
atis
tica
lba
selin
e?an
alys
is?
Har
radi
ne,
Yes
164
(2)
No
Ran
dom
No
Yes
Yes
Rep
orte
d,bu
tN
o –
but
et a
l.,19
9824
num
ber
lists
not
by g
roup
ch
arac
teri
stic
sor
no
reas
on
of n
on-
UK
for
with
draw
alre
spon
ders
wer
est
ated
exam
ined
Vond
elin
g,Ye
s (b
rief
)20
0 (2
),bu
tN
oN
ot s
tate
dN
oN
ot s
tate
dD
escr
iptiv
eN
ot s
tate
dN
ot s
tate
det
al.,
1999
29to
tal s
ampl
e no
tsu
mm
ary
yet
recr
uite
dD
enm
ark
Health Technology Assessment 2000; Vol. 4: No. 15
25
Appendix 3
Summary of data extraction and methodologicalassessment of literature reviews
Appendix 3
26 TAB
LE 3
D
ata
extra
ctio
n an
d m
etho
dolo
gica
l ass
essm
ent
of li
tera
ture
rev
iew
s
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
And
erso
n,19
9830
USA
To r
evie
w th
e fa
ctor
s re
latin
gto
the
rem
oval
of
asym
ptom
atic
thi
rd m
olar
sin
ord
er t
o he
lp d
entis
tspr
ovid
e be
tter
pat
ient
trea
tmen
t as
opp
osed
to
‘ove
rtre
atm
ent’
Tota
l ref
eren
ces:
27
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
The
bes
t ov
eral
l str
ateg
y fo
r th
e m
anag
emen
t of
asym
ptom
atic
thi
rd m
olar
s is
to
rem
ove
thos
e te
eth
that
,clin
ical
ly a
nd r
adio
grap
hica
lly,a
re e
ither
impa
cted
or h
ave
min
imal
cha
nce
for
erup
tion
befo
re t
he p
atie
ntre
ache
s th
e la
te 2
0s.F
or a
sym
ptom
atic
thi
rd m
olar
sth
at a
ppea
r to
hav
e a
chan
ce fo
r er
uptio
n or
are
erup
ted,
and
for
asym
ptom
atic
impa
cted
thi
rd m
olar
sin
old
er p
atie
nts,
peri
odic
exa
min
atio
n of
the
pat
ient
isac
cept
able
,so
long
as
the
patie
nt h
as b
een
info
rmed
of
the
rele
vant
ris
ks a
nd b
enef
its o
f obs
erva
tion
Thi
s is
a n
arra
tive
revi
ew in
whi
ch s
ubje
ctiv
eop
inio
ns a
re e
xpre
ssed
tha
t su
ppor
t th
epr
ophy
lact
ic r
emov
al o
f thi
rd m
olar
s.It
isdi
fficu
lt to
judg
e th
e co
mpr
ehen
sive
ness
and
relia
bilit
y of
the
rev
iew
as
ther
e ar
e no
deta
ils o
f a s
earc
h st
rate
gy,s
elec
tion
crite
ria
for
prim
ary
stud
ies,
or q
ualit
y as
sess
men
t of
the
data
Bert
rand
,et
al.,
1989
31
Fran
ce
The
rev
iew
obj
ectiv
e is
not
clea
rly
stat
ed,b
utap
pear
s to
be
to d
iscu
ssva
riou
s as
pect
s of
the
man
agem
ent
of w
isdo
mte
eth
Tota
l ref
eren
ces:
108
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
The
inci
denc
e of
pat
holo
gy h
as b
een
redu
ced
duri
ngth
e la
st 2
0 ye
ars
beca
use
of t
he t
ende
ncy
for
orth
odon
tists
to
syst
emat
ical
ly r
emov
e th
ird
mol
arge
rms.
The
impo
rtan
ce o
f the
cor
rect
dia
gnos
is o
fm
orbi
dity
ass
ocia
ted
with
ret
entio
n sh
ould
be
high
light
ed.T
hird
mol
ar s
urge
ry m
ay b
e as
soci
ated
with
var
ious
per
i- an
d po
st-o
pera
tive
com
plic
atio
ns
Thi
s re
view
is p
rese
nted
as
a se
ries
of
chap
ters
cov
erin
g va
riou
s as
pect
s of
thi
rdm
olar
man
agem
ent.
The
rev
iew
met
hodo
logy
is p
oor,
and
the
obje
ctiv
es a
nd c
oncl
usio
nsar
e un
clea
r.So
me
refe
renc
es a
re g
iven
for
the
sect
ion
desc
ribi
ng r
eten
tion-
asso
ciat
eddi
seas
e,an
d a
sing
le r
efer
ence
is p
rovi
ded
for
com
plic
atio
ns o
f sur
gery
.It
is u
ncle
arw
heth
er t
he r
efer
ence
s ar
e ev
alua
tions
of
path
olog
ical
cha
nges
/com
plic
atio
n ra
tes,
orw
heth
er t
hey
are
artic
les
that
mer
ely
desc
ribe
the
pro
blem
s
Health Technology Assessment 2000; Vol. 4: No. 15
27TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Bone
tti,
et a
l.,19
8833
Ital
y
To r
evie
w t
he in
dica
tions
for
thir
d m
olar
ext
ract
ion
Tota
l ref
eren
ces:
24
1.Fa
ir2.
NA
3.N
A4.
NA
5.Fa
ir6.
Fair
/–Si
nce
ther
e is
no
clea
r ev
iden
ce r
elat
ing
to t
heim
port
ance
of t
hird
mol
ars
in c
reat
ing
dent
alcr
owdi
ng,i
t is
inap
prop
riat
e to
und
erta
ke
prop
hyla
ctic
ext
ract
ion
Thi
s re
view
focu
ses
on t
he p
robl
em o
fcr
owdi
ng.R
eten
tion-
asso
ciat
ed p
atho
logi
cal
chan
ges
and
surg
ical
com
plic
atio
ns a
re li
sted
in t
able
s.T
here
are
thr
ee r
efer
ence
s in
the
text
whi
ch d
o no
t ap
pear
in t
he b
iblio
grap
hy.
No
deta
ils a
re p
rovi
ded
of s
tudy
iden
ti-fic
atio
n,se
lect
ion
or q
ualit
y
Bram
ante
,199
034
USA
To r
evie
w t
he c
urre
ntth
inki
ng o
n re
tent
ion
and
the
influ
ence
of t
hird
mol
ars
on lo
wer
ant
erio
rcr
owdi
ng (
in a
nor
thod
ontic
con
text
)
Tota
l ref
eren
ces:
64
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or/fa
ir6.
Poor
/–T
he m
andi
bula
r th
ird
mol
ar p
roba
bly
does
exe
rt a
nin
sign
ifica
nt fo
rce
on t
he d
enta
l arc
h du
ring
its
erup
tion.
How
ever
,the
thi
rd m
olar
s do
not
sig
nific
antly
influ
ence
the
cro
wdi
ng o
f the
low
er a
nter
iors
A n
umbe
r of
obs
erva
tiona
l stu
dies
wer
ere
view
ed w
ith r
egar
d to
the
ass
ocia
tion
betw
een
the
pres
ence
of t
hird
mol
ars
and
over
crow
ding
.The
re is
no
desc
ript
ion
of a
liter
atur
e se
arch
or
any
men
tion
of s
elec
tion
crite
ria
or q
ualit
y as
sess
men
t of
stu
dies
Bish
ara,
1999
32
USA
To r
evie
w s
ome
of t
hepe
rtin
ent
stud
ies
rela
ted
to t
he m
anag
emen
t of
thir
d m
olar
s in
an
orth
odon
tic c
onte
xt
Tota
l ref
eren
ces:
30
1.Fa
ir2.
NA
3.N
A4.
NA
5.Fa
ir6.
Poor
/–T
he in
fluen
ce o
f thi
rd m
olar
s on
alig
nmen
t of
ant
erio
rde
ntiti
on m
ay b
e co
ntro
vers
ial,
but
ther
e is
no
evid
ence
to
incr
imin
ate
thes
e te
eth
as b
eing
the
maj
orae
tiolo
gica
l fac
tor
in t
he p
ost-
trea
tmen
t ch
ange
s in
inci
sor
alig
nmen
t.T
he e
vide
nce
sugg
ests
tha
t th
e on
lyre
latio
nshi
p be
twee
n th
ese
two
phen
omen
a is
tha
tth
ey o
ccur
at
appr
oxim
atel
y th
e sa
me
stag
e of
deve
lopm
ent
i.e.i
n ad
oles
cenc
e an
d ea
rly
child
hood
.H
owev
er,t
his
is n
ot a
cau
se a
nd e
ffect
rel
atio
nshi
p
Mos
t of
the
dat
a ap
pear
to
be fr
omob
serv
atio
nal s
tudi
es.W
ith n
o in
form
atio
nab
out
the
sear
ch s
trat
egy,
sele
ctio
n cr
iteri
aan
d st
udy
qual
ity,f
indi
ngs
shou
ld p
roba
bly
bein
terp
rete
d w
ith c
autio
n
Appendix 3
28 TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
‡M
erri
ll R
G.P
reve
ntio
n,tr
eatm
ent
and
prog
nosi
s fo
r ne
rve
inju
ry r
elat
ed t
o th
e di
fficu
lt im
pact
ion.
Den
t Cl
in N
orth
Am
1979
;23:
471–
87N
A =
not
rep
orte
d
cont
inue
d
Chi
khan
i,et
al.,
1994
37
Fran
ce
The
obj
ectiv
es a
re n
otex
plic
itly
stat
ed b
y th
eau
thor
s,bu
t ap
pear
to
beto
dis
cuss
ling
ual n
erve
inju
ry d
urin
g ex
trac
tion
ofm
andi
bula
r w
isdo
m t
eeth
Tota
l ref
eren
ces:
13
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
The
inci
denc
e of
ling
ual n
erve
dam
age
duri
ngex
trac
tion
of m
andi
bula
r th
ird
mol
ars
is le
ss t
han
infe
rior
den
tal n
erve
dam
age,
estim
ated
at
1.3%
ver
sus
2–4%
by
mos
t au
thor
s
Thi
s re
view
focu
ses
on v
ario
us a
spec
tsre
latin
g to
ling
ual n
erve
inju
ry fo
llow
ing
thir
d m
olar
sur
gery
.The
sec
tion
onin
cide
nce
is v
ery
brie
f.R
evie
w m
etho
ds a
repo
or
Brok
aw,1
99135
USA
To r
evie
w t
heco
nsid
erat
ions
tha
t a
dent
ist
shou
ld t
ake
into
acco
unt
whe
n m
akin
gre
com
men
datio
nsco
ncer
ning
bot
h er
upte
dan
d un
erup
ted
thir
dm
olar
s
Tota
l ref
eren
ces:
9
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
Prev
entio
n of
futu
re p
robl
ems
or c
orre
ctin
g of
an
exis
ting
path
olog
ic c
ondi
tion
will
nec
essi
tate
the
rem
oval
of t
hird
mol
ars
in m
any
patie
nts
pres
entin
gth
emse
lves
in t
he d
enta
l offi
ce.T
he d
entis
t sh
ould
be
awar
e of
a n
umbe
r of
con
side
ratio
ns t
hat
are
requ
ired
to fo
rmul
ate
a di
agno
sis
and
trea
tmen
t pl
anco
ncer
ning
the
rem
oval
of t
hird
mol
ars
Thi
s is
a v
ery
brie
f rev
iew
of t
he m
orbi
dity
asso
ciat
ed w
ith r
eten
tion
of t
hird
mol
ars.
The
rev
iew
met
hods
are
ver
y po
or.T
he t
ext
is fr
eque
ntly
und
er-r
efer
ence
d,an
d ev
enw
here
ref
eren
ces
are
cite
d,re
liabi
lity
of d
ata
is u
nkno
wn
Cad
e,19
9236
USA
To r
evie
w p
arae
sthe
sia
ofth
e in
feri
or a
lveo
lar
nerv
eas
a r
esul
t of
the
extr
actio
n of
the
man
dibu
lar
thir
d m
olar
s
Tota
l ref
eren
ces:
17
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/
The
bes
t ad
vice
for
prev
entio
n of
infe
rior
alv
eola
rne
rve
inju
ry (
quot
ed fr
om M
erri
ll,19
79)‡ :“
ther
e is
prob
ably
no
bett
er w
ay t
o av
oid
inju
ry t
o th
e in
feri
oral
veol
ar n
erve
tha
n by
pro
phyl
actic
rem
oval
of
man
dibu
lar
thir
d m
olar
s be
fore
roo
ts a
re c
ompl
etel
yfo
rmed
.Inj
ury
to t
he n
erve
s is
unu
sual
in p
atie
nts
unde
r th
e ag
e of
18”
Thi
s is
a b
rief
rev
iew
of 3
ret
rosp
ectiv
est
udie
s or
cas
e re
port
s,an
d so
me
anat
omy
or p
hysi
olog
y st
udie
s.T
he ‘b
est
advi
ce’ f
rom
the
auth
or q
uote
d is
not
bas
ed o
n th
eev
iden
ce in
clud
ed in
the
rev
iew
Health Technology Assessment 2000; Vol. 4: No. 15
29TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Dal
ey,1
99619
Can
ada
To r
evie
w t
hird
mol
arpr
ophy
lact
ic e
xtra
ctio
nw
ith r
espe
ct t
o th
epa
thol
ogic
al c
hang
esas
soci
ated
with
impa
cted
thir
d m
olar
s,an
d th
eas
sum
ptio
n th
at y
oung
erpa
tient
s ha
ve s
igni
fican
tlyle
ss p
ost-
oper
ativ
em
orbi
dity
com
pare
d w
ithol
der
peop
le.
Tota
l ref
eren
ces:
145
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or/fa
ir6.
Fair
/–D
ata
indi
cate
tha
t th
e ri
sk o
f pat
holo
gica
l cha
nges
asso
ciat
ed w
ith im
pact
ed t
hird
mol
ars
or t
heir
folli
cles
is lo
w in
mid
dle-
age[
d] a
nd o
lder
peo
ple,
who
exh
ibit
asl
ight
ly h
ighe
r ri
sk o
f inc
reas
ed s
urgi
cal m
orbi
dity
tha
nyo
unge
r in
divi
dual
s.Ba
sed
on a
vaila
ble
data
,rou
tine
prop
hyla
ctic
thi
rd m
olar
ext
ract
ion
is u
njus
tifia
ble
The
cov
erag
e of
lite
ratu
re is
mor
eco
mpr
ehen
sive
tha
n in
man
y ot
her
revi
ews.
List
s of
ref
eren
ces
are
pres
ente
d in
tab
les
acco
rdin
g to
diff
eren
t pa
thol
ogic
al a
nd p
ost-
oper
ativ
e ou
tcom
es.H
owev
er,t
here
is a
lack
of in
form
atio
n ab
out
revi
ew m
etho
ds.T
here
is a
n an
alys
is o
f the
rat
es o
f sur
gica
lco
mpl
icat
ions
in o
lder
and
you
nger
popu
latio
ns
Dén
es,e
t al
.,19
9338
Hun
gary
Not
cle
ar,b
ut a
ppea
rs t
obe
to
disc
uss
the
prob
lem
sas
soci
ated
with
impa
cted
thir
d m
olar
s
Tota
l ref
eren
ces:
9
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/
Prop
hyla
ctic
rem
oval
of t
hird
mol
ars
is r
ecom
men
ded
beca
use
it re
duce
s th
e an
ticip
ated
pro
blem
s an
d is
adva
ntag
eous
for
orth
odon
tic t
reat
men
t
The
mai
n fo
cus
of t
he r
evie
w is
cro
wdi
ngas
soci
ated
with
thi
rd m
olar
ret
entio
n.T
here
view
met
hodo
logy
is p
oor,
with
ver
y fe
wde
tails
pro
vide
d fo
r pr
imar
y st
udie
s
Appendix 3
30 TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
ECR
I,19
9339
USA
To r
evie
w fa
ctor
sco
ncer
ning
the
rem
oval
of
man
dibu
lar
thir
d m
olar
s
Tota
l ref
eren
ces:
21(c
hapt
er 4
)
1.Po
or2.
NA
3.N
A4.
Poor
5.Po
or/fa
ir6.
Fair
+/–
The
re a
re n
o re
liabl
e pr
edic
tors
of p
atho
logy
.No
cont
rolle
d lo
ngitu
dina
l stu
dies
hav
e ex
amin
ed t
heef
fect
iven
ess
of p
roph
ylac
tic w
isdo
m t
eeth
rem
oval
.In
the
abse
nce
of s
uch
stud
ies,
it se
ems
that
pro
phyl
actic
rem
oval
dec
reas
es t
he li
kelih
ood
of fu
ture
pat
holo
gyan
d po
st-o
pera
tive
com
plic
atio
ns,b
ut d
oes
not
alle
viat
e an
teri
or d
enta
l arc
h cr
owdi
ng.H
owev
er,
surg
ery
may
ben
efit
only
one
in s
ix p
atie
nts.
Furt
herm
ore,
perf
orm
ing
prop
hyla
ctic
sur
gery
on
all
patie
nts
subj
ects
the
m t
o po
tent
ial r
isks
from
pos
t-op
erat
ive
com
plic
atio
ns s
uch
as n
erve
dam
age
Thi
s is
a r
elat
ivel
y co
mpr
ehen
sive
lite
ratu
rere
view
.The
ana
lysi
s in
clud
es d
isea
seas
soci
ated
with
ret
entio
n of
thi
rd m
olar
s,po
st-o
pera
tive
com
plic
atio
ns,r
ates
of t
hese
by a
ge o
f pat
ient
s,co
st-e
ffect
iven
ess,
and
ade
cisi
on t
ree
cons
truc
ted
from
ass
umpt
ions
deri
ved
from
the
lite
ratu
re.I
t is
diff
icul
t to
asse
ss t
he m
etho
dolo
gica
l qua
lity
of t
here
view
bec
ause
of t
he la
ck o
f inf
orm
atio
nab
out
met
hods
and
sou
rces
use
d
Flic
k,19
9940
USA
To s
umm
aris
e th
e cu
rren
tre
sear
ch a
vaila
ble
conc
erni
ng t
he r
emov
al o
fim
pact
ed t
hird
mol
ars,
and
prov
ide
a ba
ckgr
ound
from
whi
ch p
ract
ition
ers,
publ
iche
alth
pol
icy
advo
cate
s,an
d th
ird-
part
y pa
yers
can
mor
e ob
ject
ivel
y as
sess
the
issu
es o
fap
prop
riat
enes
s of
car
ean
d ov
erut
ilisa
tion
of t
hird
mol
ar s
urge
ry
Tota
l ref
eren
ces:
29
1.Fa
ir2.
NA
3.N
A4.
Poor
5.Po
or6.
Poor
+/–
The
re is
a n
eed
for
larg
e po
pula
tion-
base
d st
udie
s to
prov
ide
prac
titio
ners
with
dat
a to
hel
p th
em d
ecid
ew
hen
thir
d m
olar
sur
gery
is a
ppro
pria
te.T
here
is li
ttle
agre
emen
t on
how
man
y th
ird
mol
ars
are
bein
gre
mov
ed fo
r so
-cal
led
prop
hyla
ctic
rea
sons
.The
avai
labl
e no
n-in
terv
entio
n st
udie
s ar
e fe
w a
nd h
ave
sign
ifica
nt fl
aws.
The
stu
dies
tha
t ar
gue
agai
nst
prop
hyla
ctic
rem
oval
are
larg
ely
base
d on
sta
tistic
alm
odel
s.T
he a
pplic
atio
n of
the
se m
odel
s as
a b
asis
for
clin
ical
dec
isio
n m
akin
g is
que
stio
nabl
e.T
he e
ffect
s of
prov
ider
sup
ply
and
reim
burs
emen
t m
ust
beco
nsid
ered
as
an in
tegr
al p
art
of t
he c
ontr
over
sy
Initi
ally
thi
s re
view
see
ms
quite
pro
mis
ing,
but
does
not
in fa
ct in
clud
e a
very
com
preh
ensi
ve c
over
age
of t
he li
tera
ture
.T
here
are
sec
tions
on
rete
ntio
n-as
soci
ated
mor
bidi
ty,o
utco
mes
of s
urge
ry,a
nd c
ost-
effe
ctiv
enes
s.Fo
r th
e fir
st t
wo,
the
data
prov
ided
are
ver
y ge
nera
l.Fo
r co
st-
effe
ctiv
enes
s,da
ta a
re d
iscu
ssed
with
in a
Nor
th A
mer
ican
con
text
.The
ver
y ge
nera
lna
ture
of t
he n
arra
tive,
toge
ther
with
a la
ckof
info
rmat
ion
abou
t th
e re
view
met
hods
,m
eans
tha
t re
sults
sho
uld
be in
terp
rete
dw
ith c
autio
n
Health Technology Assessment 2000; Vol. 4: No. 15
31TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Fors
sell
& M
iett
inen
,19
8841
Finl
and
To e
xam
ine
indi
catio
ns a
ndco
ntra
indi
catio
ns fo
r th
ere
mov
al o
f man
dibu
lar
thir
d m
olar
s.To
exa
min
eth
e ef
fect
s of
tre
atm
ent
indi
ffere
nt a
ge g
roup
s
Tota
l ref
eren
ces:
23
1.Fa
ir2.
NA
3.N
A4.
NA
5.Fa
ir6.
Poor
/–W
isdo
m t
eeth
ext
ract
ion
in y
oung
er p
eopl
e in
volv
esfe
wer
and
less
sev
ere
com
plic
atio
ns.H
owev
er,r
emov
alsh
ould
not
be
cons
ider
ed a
s ro
utin
e
Thi
s re
view
focu
ses
mai
nly
on t
hepa
thol
ogic
al c
hang
es a
nd s
ympt
oms
asso
ciat
ed w
ith t
hird
mol
ar r
eten
tion,
alth
ough
the
re a
re a
sm
all n
umbe
r of
refe
renc
es r
elat
ing
to s
urgi
cal c
ompl
icat
ions
.R
efer
ence
s ar
e ci
ted
in t
he t
ext
but
abi
blio
grap
hy is
not
pro
vide
d;it
is s
tate
d th
atth
is is
ava
ilabl
e el
sew
here
via
the
jour
nal.
Alth
ough
rea
sona
ble
stud
y de
tails
are
giv
en(e
.g.s
ampl
e si
zes)
,the
rev
iew
met
hodo
logy
is g
ener
ally
poo
r
Gar
attin
i,et
al.,
1990
42
Ital
y
To r
evie
w t
he li
tera
ture
on
the
role
of t
he m
andi
bula
rth
ird
mol
ar o
n cr
owdi
ng;
to r
evie
w t
he r
ole
ofge
rmec
tom
y as
atr
eatm
ent
Tota
l ref
eren
ces:
48
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or6.
Fair
/–M
andi
bula
r th
ird
mol
ars
are
only
one
of s
ever
al fa
ctor
sw
hich
may
con
trib
ute
to m
aloc
clus
ion.
Ger
mec
tom
ysh
ould
be
perf
orm
ed in
sel
ecte
d pa
tient
s on
ly,af
ter
aco
mpr
ehen
sive
dia
gnos
tic e
valu
atio
n on
an
indi
vidu
alba
sis
The
mai
n fo
cus
of t
his
revi
ew is
the
pro
blem
of c
row
ding
ass
ocia
ted
with
ret
entio
n of
thir
d m
olar
s.Si
nce
no d
etai
ls a
re p
rovi
ded
ofid
entif
icat
ion,
sele
ctio
n,or
app
rais
al o
fpr
imar
y st
udie
s,fin
ding
s sh
ould
be
trea
ted
with
cau
tion
Goi
a,et
al.,
1990
43
Ital
y
To r
evie
w t
he in
dica
tions
for
extr
actio
n of
impa
cted
thir
d m
olar
s
Tota
l ref
eren
ces:
20
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or6.
Fair
/–T
hird
mol
ar e
xtra
ctio
n sh
ould
be
perf
orm
ed o
nly
inca
ses
of s
ever
e cr
owdi
ng.I
n ca
ses
of s
light
cro
wdi
ng,
thir
d m
olar
s sh
ould
be
reta
ined
as
they
hav
e a
posi
tive
role
Thi
s re
view
focu
ses
on t
he p
robl
em o
fcr
owdi
ng.S
ome
usef
ul d
etai
ls o
f pri
mar
yst
udie
s ar
e pr
ovid
ed,r
elat
ing
to n
umbe
rs o
fpa
tient
s an
d le
ngth
of f
ollo
w-u
p.H
owev
er,
sinc
e no
info
rmat
ion
is g
iven
for
sour
ces
ofst
udie
s,no
r of
the
ir s
elec
tion
orm
etho
dolo
gica
l qua
lity,
the
revi
ew’s
findi
ngs
shou
ld b
e in
terp
rete
d w
ith c
autio
n
Appendix 3
32 TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Jacq
uiér
y,et
al.,
1994
44
Switz
erla
nd
To p
rese
nt t
he in
dica
tions
and
cont
rain
dica
tions
of
thir
d m
olar
sur
gery
Tota
l ref
eren
ces:
28
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/
The
dec
isio
n to
ext
ract
a m
andi
bula
r w
isdo
m t
ooth
isob
viou
s in
the
cas
e of
pat
holo
gy o
r re
curr
ent
peri
coro
nitis
,but
the
nee
d fo
r pr
ophy
lact
ic e
xtra
ctio
nof
asy
mpt
omat
ic w
isdo
m t
eeth
is le
ss s
o.G
ener
ally,
itis
rea
sona
ble
to e
ncou
rage
pro
phyl
actic
ext
ract
ion
inyo
ung
patie
nts
in c
ases
whe
re n
orm
al e
rupt
ion
isun
likel
y to
tak
e pl
ace.
The
num
ber
of p
ost-
oper
ativ
eco
mpl
icat
ions
in y
oung
peo
ple
is r
elat
ivel
y lo
w.I
n th
eca
se o
f tem
pora
ry c
ontr
aind
icat
ions
(ap
art
from
peri
coro
nitis
),re
ferr
al o
f the
pat
ient
to
spec
ialis
tse
rvic
es is
rec
omm
ende
d si
nce
peri
- an
d po
st-
oper
ativ
e co
mpl
icat
ions
can
be
man
aged
mor
e ea
sily
Thi
s pa
per
focu
ses
on t
he in
dica
tions
and
cont
rain
dica
tions
for
thir
d m
olar
sur
gery
.T
he r
evie
w m
etho
dolo
gy is
poo
r,w
ith n
oin
form
atio
n on
stu
dy id
entif
icat
ion,
sele
ctio
n,or
val
idity
.A
lso,
few
det
ails
of t
he p
rim
ary
stud
ies
are
give
n.T
here
fore
the
evi
denc
epr
esen
ted
shou
ld b
e in
terp
rete
d w
ithca
utio
n
Kug
elbe
rg,1
99245
Swed
en
To a
ddre
ss t
he a
dvan
ces
inth
e di
agno
sis
and
trea
tmen
t of
impa
cted
thir
d m
olar
s w
ith s
peci
alem
phas
is o
n pe
riod
onta
lhe
alth
in t
he s
econ
d m
olar
area
adj
acen
t to
the
extr
actio
n si
te
Tota
l ref
eren
ces:
29
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or/fa
ir6.
Poor
+/–
[Pre
dict
ors
for
risk
of p
erio
dont
al d
efec
t w
ere
repo
rted
.] D
etec
ting
the
pred
icto
rs in
tim
e is
cru
cial
for
prev
entio
n of
per
iodo
ntal
def
ects
.If t
hese
fact
ors
are
negl
ecte
d du
ring
ado
lesc
ence
,the
y m
ay p
redi
spos
eth
e in
divi
dual
to
adva
nced
mar
gina
l per
iodo
ntal
brea
kdow
n la
ter
in li
fe in
the
sec
ond
mol
ar a
rea
adja
cent
to
the
extr
actio
n si
te.F
or p
atie
nts
over
30
year
s of
age
,it
is b
ette
r to
avo
id s
urge
ry u
ntil
sym
ptom
s ap
pear
Thi
s re
view
pre
sent
s an
inde
x fo
r pr
edic
ting
risk
for
peri
odon
tal d
efec
ts a
fter
sur
gery
,ba
sed
mai
nly
on t
he r
evie
wer
’s ow
n st
udie
s.T
here
is li
ttle
info
rmat
ion
abou
t re
view
met
hods
,and
the
refo
re fi
ndin
gs a
re d
iffic
ult
to in
terp
ret
with
any
deg
ree
of c
onfid
ence
Health Technology Assessment 2000; Vol. 4: No. 15
33TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Lech
ien,
1995
46
Belg
ium
To r
evie
w p
atho
logy
asso
ciat
ed w
ith r
eten
tion
of im
pact
ed t
eeth
;to
revi
ew p
ossi
ble
com
plic
atio
ns o
fex
trac
tion
and
othe
rtr
eatm
ent
stra
tegi
es
Tota
l ref
eren
ces:
16
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/
Sinc
e th
e in
cide
nce
of r
eten
tion-
asso
ciat
ed p
atho
logy
and
surg
ical
com
plic
atio
ns in
crea
se[s
] w
ith a
ge,s
urgi
cal
man
agem
ent
of im
pact
ed t
hird
mol
ars
whi
ch a
re n
ot in
a fa
vour
able
pos
ition
or
whe
n po
ster
ior
erup
tion
spac
e is
inad
equa
te,i
s re
com
men
ded.
Impa
cted
tee
thw
hich
are
par
tially
or
com
plet
ely
cove
red
by s
oft
tissu
e sh
ould
als
o be
rem
oved
if t
hey
cann
ot a
dopt
ago
od p
ositi
on in
the
den
tal a
rch
Alth
ough
thi
s re
view
dis
cuss
es a
ll ty
pes
ofim
pact
ed t
eeth
,mos
t of
the
ref
eren
ces
rela
te t
o m
anag
emen
t of
thi
rd m
olar
s.St
atem
ents
mad
e in
the
tex
t ar
e no
t al
way
ssu
ppor
ted
by r
efer
ence
s.T
he r
evie
wm
etho
dolo
gy is
poo
r
Mer
cier
& P
reci
ous,
1992
15
Can
ada
To r
evie
w t
he s
cien
tific
liter
atur
e on
the
thi
rdm
olar
s as
it p
erta
ins
tobo
th r
isks
and
ben
efits
of
inte
rven
tion
and
non-
inte
rven
tion
of im
pact
edth
ird
mol
ars
Tota
l ref
eren
ces:
149
1.Fa
ir2.
NA
3.N
A4.
NA
/poo
r5.
Poor
6.Fa
ir
+/–
Abs
olut
e in
dica
tions
and
con
trai
ndic
atio
ns fo
r th
ere
mov
al o
f asy
mpt
omat
ic t
hird
mol
ars
cann
ot b
ees
tabl
ishe
d be
caus
e no
long
-ter
m s
tudi
es e
xist
whi
chva
lidat
e th
e be
nefit
to
the
patie
nt e
ither
of e
arly
rem
oval
or
of d
elib
erat
e re
tent
ion
of t
hese
tee
th.I
tap
pear
s th
at t
he b
est
gene
ral a
ppro
ach
for
the
surg
eon
is t
o re
mov
e,on
the
bas
is o
f clin
ical
judg
emen
t,so
me
teet
h be
fore
the
age
of 1
4,an
d ot
hers
bef
ore
the
age
of 2
2,w
hen
chan
ces
of e
rupt
ion
are
min
imal
.The
bes
tst
rate
gy a
fter
thi
s ag
e is
per
iodi
c ex
amin
atio
n of
patie
nts
who
hav
e be
en fu
lly in
form
ed a
bout
rel
evan
tri
sks
and
bene
fits.
Ulti
mat
ely,
the
surg
eon
mus
t w
eigh
the
fact
s an
d pu
t th
e in
tere
sts
of t
he p
atie
nt a
bove
all
else
The
rev
iew
app
ears
to
incl
ude
a go
odco
vera
ge o
f the
lite
ratu
re,b
ut t
here
are
no
deta
ils o
f rev
iew
met
hods
.Rat
es o
fm
orbi
dity
and
pos
t-op
erat
ive
com
plic
atio
nsar
e pr
esen
ted
for
mos
t of
the
indi
vidu
alst
udie
s,bu
t th
ere
is n
o re
port
ed a
sses
smen
tof
the
val
idity
of t
he p
rim
ary
mat
eria
l.R
isks
and
bene
fits
of d
iffer
ent
stra
tegi
es a
resu
bjec
tivel
y ra
ted
and
pres
ente
d
Appendix 3
34 TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Mom
mae
rts,
et a
l.,19
9147
Belg
ium
To d
iscu
ss li
ngua
l ner
vein
jury
dur
ing
extr
actio
n of
man
dibu
lar
wis
dom
tee
th.
Tota
l ref
eren
ces:
66
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
The
inci
denc
e of
tem
pora
ry d
ysfu
nctio
n of
the
ling
ual
nerv
e ra
nges
from
0.1
% t
o 6.
6% a
cros
s st
udie
s.T
hein
cide
nce
rang
e fo
r pe
rman
ent
dysf
unct
ion
is 0
% t
o0.
1%
Alth
ough
the
det
ails
on
inci
denc
e ar
e us
eful
,th
ere
is n
o co
nsid
erat
ion
of t
he a
ppro
p-ri
aten
ess
of r
outin
e th
ird
mol
ar e
xtra
ctio
nin
ligh
t of
the
se d
ata.
The
rev
iew
met
hods
are
poor
,with
few
det
ails
of t
he s
elec
tion
and
char
acte
rist
ics
of p
rim
ary
stud
ies
Pete
rson
,199
248
USA
To r
evie
w a
nd d
iscu
ssin
dica
tions
and
cont
rain
dica
tions
for
rem
ovin
g im
pact
ed t
eeth
Tota
l ref
eren
ces:
22
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
Whi
le n
ot e
very
impa
cted
too
th c
ause
s a
sign
ifica
ntpr
oble
m,e
ach
has
that
pot
entia
l.If
the
impa
cted
thi
rdm
olar
is p
artia
lly im
pact
ed a
nd p
artia
lly e
xpos
ed,i
tsh
ould
be
rem
oved
as
soon
as
poss
ible
.The
com
plet
ely
impa
cted
,asy
mpt
omat
ic t
hird
mol
ars
in a
patie
nt o
lder
tha
n 35
can
be
left
inta
ct u
nles
s a
path
olog
ical
con
ditio
n de
velo
ps
Thi
s is
a v
ery
brie
f lite
ratu
re r
evie
w t
hat
conc
entr
ates
on
issu
es c
once
rnin
gpe
riod
onta
l hea
ling,
but
does
incl
ude
som
eot
her
info
rmat
ion.
The
re is
no
info
rmat
ion
on t
he r
evie
w m
etho
ds,s
o th
e re
liabi
lity
ofth
e in
form
atio
n pr
esen
ted
is d
iffic
ult
toas
sess
Rob
inso
n,19
9450
UK
To d
iscu
ss t
he in
dica
tions
for
and
risk
s of
wis
dom
toot
h re
mov
al,a
nd s
ugge
stgu
idel
ines
for
deal
ing
with
the
dile
mm
a
Tota
l ref
eren
ces:
9
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
Teet
h th
at a
re s
ympt
omle
ss a
nd li
kely
to
rem
ain
so a
reno
rmal
ly b
est
left
in p
lace
.Tho
ught
less
neg
lect
of t
heap
pare
ntly
har
mle
ss im
pact
ed t
hird
mol
ar m
ay le
ad t
oun
acce
ptab
le m
orbi
dity
;on
the
othe
r ha
nd,c
aval
ier
extr
actio
n of
any
or
all t
hird
mol
ars
is t
he fu
el o
flit
igat
ion
Thi
s is
a b
rief
lite
ratu
re r
evie
w,c
over
ing
prev
alen
ce o
f thi
rd m
olar
impa
ctio
n,in
dica
tions
for
rem
oval
or
rete
ntio
n,an
dri
sks
of s
urge
ry.T
here
is n
o in
form
atio
nab
out
the
revi
ew m
etho
ds,s
o th
ein
form
atio
n re
port
ed is
diff
icul
t to
ass
ess
inte
rms
of r
elia
bilit
y
Rob
inso
n &
Vas
ir,19
9349
UK
To d
iscu
ss t
he im
pact
of
man
dibu
lar
thir
d m
olar
son
inci
sor
crow
ding
Tota
l ref
eren
ces:
17
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or6.
Fair
/–M
etho
ds o
f pre
dict
ing
thir
d m
olar
beh
avio
ur a
reun
relia
ble.
The
man
dibu
lar
thir
d m
olar
has
a w
eak
asso
ciat
ion
with
late
cro
wdi
ng o
f low
er in
ciso
rs.
Idea
lly,R
CT
s w
ith la
rge
sam
ples
,mat
ched
in r
espe
ct o
fsp
ecifi
c va
riab
les,
will
pro
vide
cle
arer
ans
wer
s
Thi
s re
view
con
cent
rate
s sp
ecifi
cally
on
the
aspe
ct o
f cro
wdi
ng a
nd t
hird
mol
ars.
The
reis
no
info
rmat
ion
abou
t re
view
met
hods
.The
auth
ors
poin
t ou
t th
at a
ll th
e st
udie
sre
view
ed a
re o
f ret
rosp
ectiv
e de
sign
,or
have
othe
r w
eakn
esse
s
Health Technology Assessment 2000; Vol. 4: No. 15
35TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Sand
s,et
al.,
1993
51,5
2
Can
ada
To r
evie
w t
he li
tera
ture
on
the
maj
or c
ontr
over
sies
and
disc
uss
som
e of
the
mis
conc
eptio
ns a
ssoc
iate
dw
ith t
hird
mol
ar s
urge
ry
Tota
l ref
eren
ces:
72
1.Po
or2.
NA
3.N
A4.
NA
/poo
r5.
Poor
/fair
6.Fa
ir
/–T
here
is a
ten
denc
y to
exa
gger
ate
the
inci
denc
e of
sign
ifica
nt p
atho
logy
ass
ocia
ted
with
impa
cted
thi
rdm
olar
s.T
he s
ugge
stio
n th
at a
ll w
isdo
m t
eeth
sho
uld
bere
mov
ed c
anno
t be
sup
port
ed
Thi
s re
view
cov
ers
both
ret
entio
n-re
late
dm
orbi
dity
and
pos
t-op
erat
ive
com
plic
atio
ns.
The
re is
no
info
rmat
ion
abou
t th
e re
view
met
hods
,so
it is
diff
icul
t to
ass
ess
the
relia
bilit
y of
the
dat
a
Sout
hard
,199
253
USA
To r
evie
w r
ecen
t ev
iden
ceon
thi
rd m
olar
and
inci
sor
crow
ding
and
the
appr
opri
aten
ess
ofre
mov
al
Tota
l ref
eren
ces:
21
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
/–R
emov
ing
impa
cted
thi
rd m
olar
s fo
r th
e ex
clus
ive
purp
ose
of r
elie
ving
inte
rden
tal f
orce
and
the
reby
prev
entin
g in
ciso
r cr
owdi
ng is
unw
arra
nted
Thi
s re
view
con
cent
rate
s on
the
impa
ct o
fun
erup
ted
thir
d m
olar
s on
inci
sor
crow
ding
.Be
caus
e th
ere
are
no d
etai
ls o
f rev
iew
met
hods
,the
info
rmat
ion
pres
ente
d m
ay b
eof
lim
ited
relia
bilit
y
Step
hens
,et
al.,
1989
13
Can
ada
To c
ritic
ally
eva
luat
e th
esc
ient
ific
liter
atur
e us
ed a
sth
e ba
sis
for
the
ratio
nale
of p
roph
ylac
tic r
emov
al o
fun
erup
ted
or im
pact
edth
ird
mol
ars
Tota
l ref
eren
ces:
65
1.Fa
ir2.
NA
3.N
A4.
Poor
/fair
5.Po
or/fa
ir6.
Fair
/–Pr
ophy
lact
ic r
emov
al o
f asy
mpt
omat
ic o
r no
n-pa
thol
ogic
ally
invo
lved
impa
cted
tee
th is
a q
uest
iona
ble
prac
tice.
Extr
actio
n sh
ould
be
limite
d to
tho
se t
eeth
with
def
ined
pat
holo
gic
indi
catio
ns s
uch
as in
fect
ion,
cyst
s,tu
mou
rs,r
esor
ptio
n an
d un
rest
orab
le c
arie
s
Det
ails
of r
evie
w m
etho
ds w
ere
not
pres
ente
d,so
the
rel
iabi
lity
of t
he r
evie
wca
nnot
be
asse
ssed
.The
re is
mor
e de
tail
onth
e pr
imar
y st
udie
s,co
mpa
red
with
man
yot
her
revi
ews
Appendix 3
36 TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
Teal
di &
Dom
ini,
1986
55
Ital
y
To r
evie
w p
ublis
hed
stud
ies
on t
he in
dica
tions
for
extr
actin
g im
pact
edth
ird
mol
ars
Tota
l ref
eren
ces:
15
1.Fa
ir2.
NA
3.N
A4.
NA
5.Po
or6.
Fair
+/–
The
con
trai
ndic
atio
ns t
o ex
trac
ting
impa
cted
man
dibu
lar
thir
d m
olar
s ar
e:ab
senc
e of
mol
ars
or p
re-
mol
ars,
inte
ntio
n to
ext
ract
firs
t or
sec
ond
perm
anen
tm
olar
,and
ext
ract
ion
of fi
rst
or s
econ
d m
olar
due
to
cari
es/p
erio
dont
itis.
The
re is
a la
ck o
f con
sens
usre
latin
g to
the
indi
catio
ns fo
r re
mov
al o
f im
pact
edth
ird
mol
ars,
apar
t fr
om c
ases
of t
hird
mol
ar c
arie
s,or
whe
n cy
sts/
tum
ours
are
pre
sent
Thi
s re
view
focu
ses
on t
he p
robl
ems
ofth
ird
mol
ar r
eten
tion.
The
obj
ectiv
es a
recl
ear,
and
som
e us
eful
det
ails
of t
he p
rim
ary
stud
ies
are
give
n.H
owev
er,t
here
are
no
deta
ils o
f how
stu
dies
wer
e id
entif
ied
orse
lect
ed.T
here
is a
ref
eren
ce in
the
tex
t th
atis
not
incl
uded
in t
he b
iblio
grap
hy
Torr
es,1
99756
Fran
ce
To d
eter
min
e w
hy,w
hen,
and
whi
ch t
eeth
sho
uld
bere
mov
ed o
r re
tain
ed
Tota
l ref
eren
ces:
33
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Fair
/–In
clin
ical
pra
ctic
e,it
is li
kely
tha
t a
very
larg
epr
opor
tion
of w
isdo
m t
eeth
are
ext
ract
ed w
ithou
tin
dica
tion.
Such
inte
rven
tions
,with
out
clin
ical
mot
ive,
can
lead
to
min
or h
ealth
pro
blem
s,as
wel
l as
cons
ider
able
cos
ts r
elat
ing
to a
bsen
ce fr
om w
ork,
conv
ales
cenc
e,an
d m
edic
o-le
gal o
utco
mes
for
prac
titio
ners
Thi
s re
view
att
empt
s to
dis
cuss
the
ris
ksan
d be
nefit
s as
soci
ated
with
ret
entio
n an
dre
mov
al o
f wis
dom
tee
th.T
he r
evie
wm
etho
dolo
gy is
gen
eral
ly p
oor.
Seve
ral
refe
renc
es a
re c
ited
for
diffe
rent
asp
ects
of
rete
ntio
n-as
soci
ated
pat
holo
gy a
nd s
urgi
cal
com
plic
atio
ns
Tate
,199
454
USA
To r
evie
w t
he a
etio
logy
and
pote
ntia
l pat
holo
gy o
fim
pact
ed t
eeth
,and
disc
uss
indi
catio
ns a
ndco
ntra
indi
catio
ns fo
rex
trac
tion
Tota
l ref
eren
ces:
27
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/
The
ove
rwhe
lmin
g bo
dy o
f evi
denc
e sh
ows
that
patie
nts
who
wai
t un
til s
ympt
oms
deve
lop
befo
reha
ving
impa
cted
tee
th r
emov
ed s
uffe
r un
due
disc
omfo
rt,p
rolo
nged
rec
over
y an
d in
crea
sed
expe
nse,
as w
ell a
s da
mag
e to
the
bon
y su
ppor
t of
adja
cent
tee
th.T
hus,
in t
he a
bsen
ce o
f act
ive
sym
ptom
s,th
e in
dica
tions
for
rem
oval
of i
mpa
cted
teet
h fa
ll cl
earl
y in
the
rea
lm o
f pre
vent
ive
dent
istr
y
The
re is
no
info
rmat
ion
on r
evie
w m
etho
ds,
and
so it
is n
ot p
ossi
ble
to a
sses
s th
eev
iden
ce p
rese
nted
Seve
ral s
tudi
es a
bout
pat
holo
gica
l cha
nges
asso
ciat
ed w
ith r
etai
ned
thir
d m
olar
s w
ere
revi
ewed
but
onl
y on
e ab
out
com
plic
atio
nsaf
ter
thir
d m
olar
sur
gery
.It
is p
ossi
ble
that
avai
labl
e ev
iden
ce h
as b
een
sele
cted
to
supp
ort
the
auth
or’s
belie
fs a
nd p
ract
ice
Health Technology Assessment 2000; Vol. 4: No. 15
37TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
cont
inue
d
van
der
Lind
en,e
t al
.,19
9357
Sout
h A
fric
a
To r
evie
w/d
iscu
ss t
heap
prop
riat
enes
s of
rem
oval
of t
hird
mol
ars
Tota
l ref
eren
ces:
37
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
The
arg
umen
ts b
oth
for
and
agai
nst
the
prop
hyla
ctic
rem
oval
of i
mpa
cted
thi
rd m
olar
s ar
e al
l val
id.E
ach
case
sho
uld
be a
sses
sed
on it
s m
erits
.The
dec
isio
nw
heth
er o
r no
t to
rem
ove
the
thir
d m
olar
s sh
ould
take
the
ove
rall
bene
fit t
o th
e pa
tient
’s or
al s
tatu
s an
dge
nera
l hea
lth in
to a
ccou
nt
Thi
s re
view
was
mai
nly
abou
t th
e in
dica
tions
or c
ontr
aind
icat
ions
for
thir
d m
olar
sur
gery
.T
here
is n
o in
form
atio
n ab
out
revi
ewm
etho
ds,s
o it
is d
iffic
ult
to in
terp
ret
the
evid
ence
pre
sent
ed
Vasi
r &
Rob
inso
n,19
9122
UK
To r
evie
w li
tera
ture
on
whe
ther
man
dibu
lar
thir
dm
olar
s af
fect
inci
sor
crow
ding
Tota
l ref
eren
ces:
59
1.Po
or2.
NA
3.N
A4.
Poor
/fair
5.Po
or/fa
ir6.
Fair
/–T
he m
andi
bula
r th
ird
mol
ar h
as a
wea
k as
soci
atio
nw
ith la
te c
row
ding
of l
ower
inci
sors
Som
e de
tails
are
giv
en in
the
tex
t re
latin
g to
prim
ary
stud
ies.
How
ever
,fur
ther
info
rmat
ion
abou
t pr
imar
y m
ater
ial a
ndre
view
met
hods
wou
ld b
e re
quir
ed t
o m
ake
defin
itive
con
clus
ions
from
thi
s ev
iden
ce
Toth
,199
34
UK
To e
valu
ate
the
appr
opri
aten
ess
ofpr
ophy
lact
ic e
xtra
ctio
n of
impa
cted
thi
rd m
olar
s
Tota
l ref
eren
ces:
74
1.Fa
ir2.
Fair
3.Po
or4.
Poor
/fair
5.Fa
ir6.
Fair
/–Pr
ophy
lact
ic s
urge
ry is
not
an
appr
opri
ate
man
agem
ent
stra
tegy
for
asym
ptom
atic
impa
cted
thi
rd m
olar
s.C
urre
nt e
vide
nce
does
not
per
mit
a co
nclu
sion
on
the
appr
opri
aten
ess
of p
roph
ylac
tic s
urge
ry w
hen
impa
cted
thi
rd m
olar
s ha
ve b
een
asso
ciat
ed w
ith o
neor
mor
e ep
isod
e of
pat
holo
gy
Thi
s re
view
is b
ette
r th
an m
any
othe
rs in
that
it m
entio
ns a
sea
rch
stra
tegy
,giv
esus
eful
det
ails
abo
ut s
ome
of t
he p
rim
ary
stud
ies,
and
high
light
s so
me
of t
he p
robl
ems
with
in t
he p
rim
ary
stud
ies.
Furt
her
deta
ilsab
out
the
revi
ew m
etho
ds (
i.e.h
ow s
tudi
esw
ere
sele
cted
) w
ould
hav
e be
en u
sefu
l.The
com
plic
atio
ns a
fter
thi
rd m
olar
sur
gery
wer
eno
t re
view
ed
Appendix 3
38 TAB
LE 3
con
td
Dat
a ex
tract
ion
and
met
hodo
logi
cal a
sses
smen
t of
lite
ratu
re r
evie
ws
Ref
eren
ce,
Obj
ecti
ves
Rev
iew
Rev
iew
’s c
onc
lusi
ons
†A
sses
sors
’ co
mm
enta
ryco
untr
ym
etho
ds*
*Re
view
met
hods
:1.D
oes
the
revie
w a
nsw
er a
wel
l-def
ined
que
stio
n? 2
.Was
a s
ubst
antia
l effo
rt t
o se
arch
for
all t
he r
elev
ant
liter
atur
e m
ade?
3.A
re t
he in
clus
ion/
excl
usio
n cr
iteria
rep
orte
d an
dap
prop
riate
? 4.
Is t
he v
alid
ity o
f inc
lude
d st
udie
s ad
equa
tely
asse
ssed
? 5.
Is s
uffic
ient
det
ail o
f the
indi
vidua
l stu
dies
pre
sent
ed?
6.H
ave
the
prim
ary
stud
ies
been
sum
mar
ised
appr
opria
tely?
†Re
view
’s co
nclu
sion
abou
t ap
prop
riate
ness
of p
roph
ylact
ic re
mov
al o
f im
pact
ed t
hird
mol
ars:
+/–
= u
ncer
tain
;+/
= s
uppo
rtin
g pr
ophy
lact
ic re
mov
al;/
– =
aga
inst
pro
phyla
ctic
rem
oval
NA
= n
ot r
epor
ted
Wei
senf
eld
& K
ondi
s,19
9159
USA
To r
evie
w t
he li
tera
ture
on
prop
hyla
ctic
rem
oval
of
impa
cted
thi
rd m
olar
s
Tota
l ref
eren
ces:
9
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
It is
cle
ar fr
om n
umer
ous
publ
icat
ions
tha
t a
diag
nosi
sof
thi
rd m
olar
s as
pat
holo
gica
l sim
ply
beca
use
they
are
pres
ent
is n
ot a
ppro
pria
te.T
he c
linic
al d
ecis
ion
abou
tw
heth
er t
hey
shou
ld b
e ex
trac
ted
shou
ld b
e m
ade
onan
indi
vidu
al b
asis
aft
er p
rope
r co
nsid
erat
ion
of t
ooth
deve
lopm
ent,
posi
tion,
size
,pat
ient
age
,and
gro
wth
pote
ntia
l
Thi
s re
view
is e
xtre
mel
y br
ief.
It is
diff
icul
tto
infe
r m
uch
from
thi
s pa
per,
due
to it
sbr
evity
,and
lack
of d
etai
l abo
ut m
etho
ds
Wai
te &
Rey
nold
s,19
9858
USA
To d
iscu
ss fa
ctor
s re
late
dto
impa
cted
tee
th a
nd h
elp
the
orth
odon
tist
unde
rsta
nd t
he g
ener
alm
anag
emen
t of
impa
cted
thir
d m
olar
s
Tota
l ref
eren
ces:
28
1.Po
or2.
NA
3.N
A4.
NA
5.Po
or6.
Poor
+/–
The
ben
efit
of p
roph
ylac
tic r
emov
al o
f thi
rd m
olar
s is
the
poss
ible
pre
vent
ion
of p
oten
tial d
isea
se a
t a
time
whe
n th
e su
rgic
al r
isk
is m
inim
al.U
ltim
atel
y,th
ede
cisi
on t
o re
mov
e im
pact
ed t
hird
mol
ars
is b
ased
on
a va
riet
y of
fact
ors
judg
ed t
o be
impo
rtan
t by
the
patie
nt a
nd t
he d
entis
t.Fu
rthe
r re
sear
ch is
nee
ded
befo
re c
ateg
oric
al d
ecis
ions
can
be
esta
blis
hed
for
the
man
agem
ent
of im
pact
ed t
hird
mol
ars
The
re is
no
info
rmat
ion
on r
evie
w m
etho
ds,
so it
is n
ot p
ossi
ble
to a
sses
s re
liabi
lity
ofda
ta.T
his
revi
ew c
once
ntra
tes
mor
e on
path
olog
y ra
ther
tha
n co
mpl
icat
ions
of
surg
ery
Health Technology Assessment 2000; Vol. 4: No. 15
39
Appendix 4
Data extraction summary for decision analysis studies
Appendix 4
40 TAB
LE 4
D
ata
extra
ctio
n su
mm
ary
for
decis
ion
anal
ysis
stud
ies
Ref
eren
ce,
Str
ateg
ies
Out
com
e an
d ut
ility
Pro
babi
lity
esti
mat
ing
Co
st e
stim
atin
gM
ain
findi
ngs
Sen
siti
vity
ana
lysi
sco
untr
yco
mpa
red
esti
mat
ing
3M(s
) =
thi
rd m
olar
(s)
cont
inue
d
Tullo
ch &
Ant
czak
-Bo
ucko
ms,
1987
61
USA
1.R
emov
ing
all 3
Ms
2.R
emov
ing
only
impa
cted
3M
s
3.R
emov
ing
impa
cted
3M
sw
ith d
isea
se
Com
plic
atio
ns a
ssoc
iate
dw
ith r
emov
al o
f 3M
s.
DSD
is d
efin
ed in
ter
ms
ofth
e di
sabi
lity
norm
ally
asso
ciat
ed w
ith a
nun
com
plic
ated
sur
gica
lex
trac
tion
of a
3M
–na
mel
y,pa
in,s
wel
ling,
brui
sing
and
mal
aise
.46
clin
icia
ns (
oral
sur
geon
s,or
thod
ontis
ts o
r ge
nera
lde
ntis
ts)
wer
e as
ked
tora
te t
he v
alue
of D
SDac
cord
ing
to t
heir
bel
ief
abou
t th
e m
orbi
dity
or
disa
bilit
y as
soci
ated
with
each
com
plic
atio
n
Prob
abili
ty o
f eac
hco
mpl
icat
ion
was
subj
ectiv
ely
estim
ated
by a
gro
up o
f exp
erts
usin
g a
Del
phi
tech
niqu
e
The
pro
port
ion
of3M
s w
ith v
ario
usde
gree
s of
impa
ctio
nan
d th
e pr
obab
ility
of
dise
ase
asso
ciat
ed w
ithre
tain
ed 3
Ms
wer
ede
rive
d fr
om t
hepu
blis
hed
liter
atur
e
–U
nder
a w
ide
rang
e of
assu
mpt
ions
abo
ut t
helik
elih
ood
of d
iffer
ent
impa
ctio
n ty
pes,
chan
ceof
dis
ease
,pro
babi
lity
of e
xtra
ctio
nco
mpl
icat
ions
,and
disa
bilit
y as
soci
ated
with
eac
h co
mpl
icat
ion,
the
stra
tegy
of
extr
actin
g on
ly d
isea
se-
asso
ciat
ed im
pact
edm
andi
bula
r 3M
s is
gene
rally
the
ris
k-m
inim
isin
g op
tion
For
each
inpu
tpa
ram
eter
,3 e
stim
ates
wer
e us
ed:l
ow,c
entr
al,
and
high
val
ue.T
here
sults
usi
ng t
hese
3va
lues
wer
e co
nsis
tent
.T
he fi
ndin
g w
asse
nsiti
ve t
o th
ese
veri
ty o
f the
outc
ome,
alth
ough
onl
yw
hen
thes
e va
lues
beco
me
rath
erex
trem
e
Tullo
ch,e
t al
.,19
9062
USA
1.R
emov
ing
all 3
Ms
2.R
emov
ing
only
impa
cted
3M
s
3.R
emov
ing
impa
cted
3M
sw
ith d
isea
se
Cos
ts a
nd c
ompl
icat
ions
asso
ciat
ed w
ith r
emov
al o
f3M
s
DSD
is d
efin
ed a
ndes
timat
ed a
s in
Tul
loch
&A
ntcz
ak-B
ouck
oms
(198
7)61
Prob
abili
ty o
fco
mpl
icat
ions
,3M
sw
ith v
ario
us d
egre
esof
impa
ctio
n,an
ddi
seas
e as
soci
ated
with
reta
ined
3M
s w
ere
estim
ated
as
in T
ullo
ch&
Ant
czak
-Bou
ckom
s(1
987)
61
The
cos
ts o
f the
surg
ical
pro
cedu
re a
ndof
tre
atin
g an
y di
seas
eor
com
plic
atio
ns o
fsu
rger
y w
ere
estim
ated
on
the
basi
sof
clin
icia
ns’ r
epor
ted
fee
and
a re
view
of
patie
nt r
ecor
ds
Rem
ovin
g on
ly t
hose
3Ms
that
rem
ain
impa
cted
and
bec
ome
asso
ciat
ed w
ith d
isea
seis
alw
ays
asso
ciat
edw
ith le
ss e
xpec
ted
cost
and
disa
bilit
y th
anpr
ophy
lact
ic r
emov
al o
fas
ympt
omat
ic w
isdo
mte
eth
The
opt
imal
str
ateg
y(r
eten
tion
of 3
Ms)
rem
aine
d th
e sa
me
unde
r bo
th t
he ‘b
est-
case
’ sce
nari
o an
d th
e‘w
orst
-cas
e’ s
cena
rio
Health Technology Assessment 2000; Vol. 4: No. 15
41TAB
LE 4
con
td
Dat
a ex
tract
ion
sum
mar
y fo
r de
cisio
n an
alys
is st
udie
s
Ref
eren
ce,
Str
ateg
ies
Out
com
e an
d ut
ility
Pro
babi
lity
esti
mat
ing
Co
st e
stim
atin
gM
ain
findi
ngs
Sen
siti
vity
ana
lysi
sco
untr
yco
mpa
red
esti
mat
ing
*N
ot d
iscus
sed
in d
etai
l in
the
text
bec
ause
it c
onsid
ers
only
the
econ
omic
cons
eque
nces
of d
iffer
ent
stra
tegi
es3M
(s)
= t
hird
mol
ar(s
);VAS
= v
isual
ana
logu
e sc
ale
cont
inue
d
ECR
I,19
9339
*
USA
1.Pr
ophy
lact
icsu
rger
y
2.N
o pr
ophy
lact
icsu
rger
y
Econ
omic
con
sequ
ence
sPr
obab
ilitie
s of
com
plic
atio
nsfo
llow
ing
3M s
urge
ryw
ere
base
d on
dat
afr
om t
he li
tera
ture
Cos
ts w
ere
take
n fr
omth
e hi
gh e
nd o
f fee
sre
port
ed in
199
0 in
the
publ
ishe
dlit
erat
ure
It is
cos
t-ef
fect
ive
tode
ny p
roph
ylac
ticsu
rger
y if
less
tha
n 30
%of
the
non
-pr
ophy
lact
ical
ly t
reat
edpa
tient
s re
quir
e su
rger
yaf
ter
20 y
ears
Diff
eren
t pe
rcen
tage
sof
pat
ient
s un
derg
oing
prop
hyla
ctic
sur
gery
and/
or d
iffer
ent
perc
enta
ges
of p
atie
nts
requ
irin
g su
rger
y w
ere
used
in t
he m
odel
Bric
kley
,et
al.,
1995
26
UK
1.R
emov
ing
all
impa
cted
3M
s
2.C
onse
rvat
ive
trea
tmen
t
Out
com
es fo
llow
ing
surg
ical
rem
oval
of l
ower
3Ms,
or fo
llow
ing
non-
inte
rven
tion
Util
ities
of t
he o
utco
mes
wer
e m
easu
red
usin
g a
VAS,
rate
d by
104
indi
vidu
als,
age-
and
sex
-mat
ched
to
aco
hort
of p
atie
nts
who
had
unde
rgon
e lo
wer
3M
surg
ery.
Zer
o in
dica
tes
‘thin
gs c
ould
not
be
wor
se’
and
100
indi
cate
s ‘I
wou
ldno
t be
bot
here
d at
all’
The
pro
babi
lity
of e
ach
outc
ome
was
estim
ated
usi
ng a
liter
atur
e re
view
(a
com
pute
rise
d se
arch
and
a re
view
by
Mer
cier
& P
reci
ous,
1992
15),
and
data
from
an a
udit
of 3
00co
nsec
utiv
e pa
tient
sw
ith 3
M p
robl
ems
–T
he m
axim
um e
xpec
ted
utili
ty o
f pro
phyl
actic
3M s
urge
ry (
60.2
5) w
aslo
wer
tha
n th
at fo
rno
n-in
terv
entio
n(7
6.96
)
The
find
ing
was
sens
itive
to
chan
ges
inth
e pr
obab
ilitie
s of
occu
rren
ce o
fre
curr
ent
peri
coro
nitis
(thr
esho
ld,0
.52)
,re
sorp
tion
of a
nad
jace
nt t
ooth
(thr
esho
ld,0
.29)
,los
sof
an
adja
cent
too
th(t
hres
hold
,0.3
2),a
ndcy
stic
cha
nge
(thr
esho
ld,0
.34)
Appendix 4
42 TAB
LE 4
con
td
Dat
a ex
tract
ion
sum
mar
y fo
r de
cisio
n an
alys
is st
udie
s
Ref
eren
ce,
Str
ateg
ies
Out
com
e an
d ut
ility
Pro
babi
lity
esti
mat
ing
Co
st e
stim
atin
gM
ain
findi
ngs
Sen
siti
vity
ana
lysi
sco
untr
yco
mpa
red
esti
mat
ing
3M(s
) =
thi
rd m
olar
(s);V
AS =
visu
al a
nalo
gue
scal
e
Edw
ards
,et
al.,
1999
60
UK
1.Su
rgic
al r
emov
alof
asy
mpt
omat
icdi
seas
e-fr
ee 3
Ms
2.R
eten
tion
ofas
ympt
omat
icdi
seas
e-fr
ee 3
Ms
Cos
t an
d he
alth
out
com
esfo
llow
ing
3M r
emov
al a
ndou
tcom
es o
f ret
entio
n
Util
ities
wer
e m
easu
red
byus
ing
a VA
S.10
0 pa
tient
sw
ere
aske
d to
rat
e th
eef
fect
of e
ach
outc
ome
onth
eir
own
life.
Zer
oin
dica
tes
‘thin
gs c
ould
not
be w
orse
’ and
100
indi
cate
s ‘I
wou
ld n
ot b
ebo
ther
ed a
t al
l’
Prob
abili
ties
wer
ees
timat
ed b
ased
on
aco
mpr
ehen
sive
liter
atur
e re
view
:fro
ma
com
pute
rise
dM
EDLI
NE
sear
ch a
ndm
anua
l sea
rch
of t
hem
edic
al li
tera
ture
(196
6–98
).T
hepr
obab
ility
of e
ach
outc
ome
was
the
mea
n in
cide
nce
repo
rted
from
all
ofth
e re
leva
nt li
tera
ture
Cos
t w
as m
easu
red
inte
rms
of d
irec
tec
onom
ic c
ost
in a
nN
HS
hosp
ital a
ndin
corp
orat
edco
nsum
able
s,st
aff
cost
s,ov
erhe
ads
and
equi
vale
nt a
nnua
l cos
ts
Man
dibu
lar
3M r
eten
tion
was
less
cos
tly (
£170
),m
ore
effe
ctiv
e (6
9.5
effe
ctiv
enes
s un
its o
n a
100-
poin
t sc
ale)
and
mor
e co
st-e
ffect
ive
(£2.
43 p
er u
nit
ofef
fect
iven
ess)
tha
nre
mov
al (
cost
,£22
6;ef
fect
iven
ess
units
,63.
3;co
st-e
ffect
iven
ess,
£3.5
7).
The
incr
emen
tal r
atio
of
cost
to
effe
ctiv
enes
s fo
rre
tent
ion
vs.r
emov
al w
as–£
56/6
.2 =
–£9
.03
per
extr
a un
it of
effe
ctiv
enes
s
The
find
ing
was
sens
itive
to
chan
ges
inth
e pr
obab
ility
of
peri
coro
nitis
,pe
riod
onta
l dis
ease
and
cari
es.T
he m
ost
cost
-effe
ctiv
e st
rate
gyw
ould
alte
r fr
omre
tent
ion
to r
emov
al if
:th
e pr
obab
ility
of
peri
coro
nitis
incr
ease
sfr
om 2
2% t
o 40
%;t
hepr
obab
ility
of
peri
odon
tal d
isea
sein
crea
ses
from
5%
to
17%
;or
the
prob
abili
tyof
unr
esto
rabl
e ca
ries
in t
he s
econ
d m
olar
incr
ease
s fr
om 1
0% t
o22
%
Health Technology Assessment 2000; Vol. 4: No. 15
43
Appendix 5
Studies excluded from the reviewTABLE 5 Studies excluded from the review
Reference, country Title Reasons for exclusion
Alling & Catone, 199366 Management of impacted teeth Does not specifically focus on third molars; description of problems of impaction; no outcomes reported
USA
Anker, 199667 What is the future of third molar No references cited, therefore not a review of the removal? A critical review of the literature
Australia need for the removal of third molars
Bakos & Pyle, 199169 Odontogenic keratocyst involving Few data reported in terms of the effects of third molar impacted mandibular third molars surgery
USA
Benauwt, et al, 198968 Wisdom teeth.Arguments on the Discussion notes from seminar/workshop. No discussion question references (apart from three irrelevant ones, cited in
France the paper, but not as bibliography)
Camplin, 198770 What to do with impacted teeth? Although the paper focuses on retention-associatedproblems, there are no details on the incidence of such
Croatia problems. References are shown in the text but thereis no listed bibliography
Commissionat & Inferior alveolar nerve injury Description of radiographic and surgical techniques Roisin-Chausson, 199571 during extraction of wisdom teeth relating to inferior alveolar nerve damage; aslo covers
characteristics of different lesions, and treatment.France There is only one reference relating to incidence of
nerve damage (4 references overall)
Cooper-Newland, Management of impacted third General topic overview; no outcomes discussed199672 molar teeth
USA
Di Gianfilippo, et al., Removal of impacted teeth: Although a small bibliography is included at the end199073 indications and contraindications of the paper, no references are shown within the text
Italy
Garattini, et al., Germectomy of lower third molars: Discussion of diagnostic techniques relating to,198874 indications and contraindications and optimal age for, germectomy
Italy
Garattini, et al., 198875 Germectomy of lower third molars: Description of surgical techniquessurgical technique and selection
Italy criteria
Kalamchi & Hensher, The management of impacted Mainly about surgical technique; very few references 198776 mandibular third molars 2.Treatment cited
UK
continued
Appendix 5
44
TABLE 5 contd Studies excluded from the review
Reference, country Title Reasons for exclusion
Klein & Lorber, 199577 Historical development of surgical Historical review of surgical techniquewisdom tooth extraction
Germany
Ko, et al., 199978 Bilateral dentigerous cysts – The main purpose is to present the single casereport of an unusual case and review report; the literature review is very brief
Canada of the literature
Koerner, 199479 The removal of impacted third molars Description of different surgical techniques
USA
Kokich & Matthews, Surgical and orthodontic management Not specifically relating to third molars;199380 of impacted teeth description of surgical and orthodontic techniques
USA
Leonard, 199281 Removing third molars: a review for General topic overview with few datathe general practitioner on surgical outcomes from the literature
USA
Lytle, 199582 Etiology and indication for the Does not specifically relate to third molars;management of impacted teeth few outcome data reported from the literature
USA
MacGregor, 199083 Reduction in morbidity in the surgery Does not discuss appropriateness of removalof the third molar removal of third molars; proposes techniques and
UK agents to reduce morbidity related to surgery
Pajarola, et al., 199484 Surgical extraction of mandibular The main focus of the review is the comparisonwisdom teeth between two different surgical techniques for
Switzerland extraction; there are very few references relating tosurgery related complications
Richardson, 198985 The role of the third molar in the The main focus is a single small primary study;cause of late lower arch crowding: review of other studies is very brief
Northern Ireland a review
Sentilhes, 198886 Indications for wisdom teeth removal No references
France
Seward, et al., 198487 Unerupted and impacted teeth Does not specifically relate to third molars;not a review of the literature
UK
Stamatis & Orton, 199488 The molar extraction debate The focus of the article is extraction of second molars
Australia
Stavisky, 198989 Clinical justification for the prophyl- No references cited, therefore not a review of the actic removal of impacted third molars literature
USA
Taft & Prigoff, 198790 To extract or not to extract Discussion of how to predict impactionthird molars
USA
Turcotte, et al., 198791 The impacted third molar: extract Although a bibliography is shown (18 references),or save? no references are cited in the text
Canada
continued
Health Technology Assessment 2000; Vol. 4: No. 15
45
TABLE 5 contd Studies excluded from the review
Reference, country Title Reasons for exclusion
Turcotte, et al., 199792 Alveolitis – current opinion Focuses on methods of treating alveolitis rather than discussing appropriateness of routine extraction
Germany of third molars
Windecker & Kendzia, Third molar extraction from the Primary study, not a literature review198693 prosthetic point of view
Germany
Yamada, et al., 198594 To what extent can we keep our Does not focus on third molars.This paper is intendedown teeth? Indications for extraction as a guide for dentists relating to preservation of all
Japan teeth
Health Technology Assessment 2000; Vol. 4: No. 15
51
Health Technology Assessment panel membership
Professor John Farndon*
University of Bristol
Professor Senga Bond University of Newcastle-upon-Tyne
Professor Ian Cameron Southeast Thames Regional Health Authority
Ms Lynne Clemence Mid-Kent Health Care Trust
Professor Cam Donaldson University of Aberdeen
Professor Richard Ellis St James’s University Hospital,Leeds
Mr Ian Hammond Bedford & Shires Health & Care NHS Trust
Professor Adrian Harris Churchill Hospital, Oxford
Dr Gwyneth Lewis Department of Health
Mrs Wilma MacPherson St Thomas’s & Guy’s Hospitals,London
Dr Chris McCall General Practitioner, Dorset
Professor Alan McGregorSt Thomas’s Hospital, London
Professor Jon Nicholl University of Sheffield
Professor John NormanUniversity of Southampton
Professor Michael SheppardQueen Elizabeth Hospital,Birmingham
Professor Gordon Stirrat St Michael’s Hospital, Bristol
Dr William Tarnow-MordiUniversity of Dundee
Professor Kenneth TaylorHammersmith Hospital, London
Acute Sector Panel
continued
Past members
Chair: Professor Francis H CreedUniversity of Manchester
Professor Clifford BaileyUniversity of Leeds
Ms Tracy BuryChartered Society of Physiotherapy
Professor Collette CliffordUniversity of Birmingham
Dr Katherine Darton M.I.N.D.
Mr John Dunning Papworth Hospital, Cambridge
Mr Jonathan EarnshawGloucester Royal Hospital
Mr Leonard Fenwick Freeman Group of Hospitals, Newcastle-upon-Tyne
Professor David Field Leicester Royal Infirmary
Ms Grace Gibbs West Middlesex UniversityHospital NHS Trust
Dr Neville Goodman Southmead Hospital Services Trust, Bristol
Professor Mark Haggard MRC Institute of Hearing Research, University of Nottingham
Professor Robert Hawkins University of Manchester
Dr Duncan Keeley General Practitioner, Thame
Dr Rajan Madhok East Riding Health Authority
Dr John Pounsford Frenchay Hospital, Bristol
Dr Mark Sculpher University of York
Dr Iqbal Sram NHS Executive, North West Region
Mrs Joan Webster Consumer member
Current members
* Previous Chair
Health Technology Assessment panel membership
52
continued
Professor Anthony Culyer*
University of York
Professor Michael Baum Royal Marsden Hospital
Dr Rory Collins University of Oxford
Professor George Davey SmithUniversity of Bristol
Professor Stephen FrankelUniversity of Bristol
Mr Philip Hewitson Leeds FHSA
Mr Nick Mays King’s Fund, London
Professor Ian Russell University of York
Professor David Sackett Centre for Evidence Based Medicine, Oxford
Dr Peter Sandercock University of Edinburgh
Dr Maurice Slevin St Bartholomew’s Hospital,London
Professor Charles WarlowWestern General Hospital,Edinburgh
Methodology Group
Past members
Chair: Professor Martin BuxtonHealth Economics Research Group, Brunel University
Professor Doug Altman ICRF/NHS Centre for Statistics in Medicine, University of Oxford
Dr David Armstrong Guy’s, King’s & St Thomas’sSchool of Medicine & Dentistry, London
Professor Nicholas Black London School of Hygiene & Tropical Medicine
Professor Ann BowlingUniversity College LondonMedical School
Dr Mike Clarke UK Cochrane Centre, Oxford
Professor Paul Dieppe MRC Health Services Research Collaboration,University of Bristol
Professor Mike DrummondCentre for Health Economics,University of York
Dr Vikki Entwistle University of Aberdeen
Professor Ewan Ferlie Imperial College, London
Professor Ray FitzpatrickUniversity of Oxford
Mrs Jenny Griffin Department of Health
Professor Jeremy GrimshawUniversity of Aberdeen
Dr Stephen Harrison University of Leeds
Mr John Henderson Department of Health
Professor Richard Lilford R&D, West Midlands
Professor Theresa MarteauGuy’s, King’s & St Thomas’sSchool of Medicine & Dentistry, London
Dr Henry McQuay University of Oxford
Dr Nick Payne University of Sheffield
Professor Maggie Pearson NHS Executive North West
Dr David Spiegelhalter Institute of Public Health,Cambridge
Professor Joy TownsendUniversity of Hertfordshire
Ms Caroline WoodroffeStanding Group on Consumersin NHS Research
Current members
* Previous Chair
Professor Michael Maisey*
Guy’s & St Thomas’s Hospitals,London
Professor Andrew Adam Guy’s, King’s & St Thomas’sSchool of Medicine & Dentistry,London
Dr Pat Cooke RDRD, Trent Regional Health Authority
Ms Julia Davison St Bartholomew’s Hospital,London
Professor MA Ferguson-SmithUniversity of Cambridge
Dr Mansel Haeney University of Manchester
Professor Sean Hilton St George’s Hospital Medical School, London
Mr John Hutton MEDTAP International Inc.,London
Professor Donald Jeffries St Bartholomew’s Hospital,London
Dr Ian Reynolds Nottingham Health Authority
Professor Colin Roberts University of Wales College of Medicine
Miss Annette Sergeant Chase Farm Hospital, Enfield
Professor John Stuart University of Birmingham
Dr Ala Szczepura University of Warwick
Mr Stephen Thornton Cambridge & Huntingdon Health Commission
Dr Jo Walsworth-Bell South Staffordshire Health Authority
Diagnostics and Imaging Panel
Past members
Chair: Professor Mike SmithUniversity of Leeds
Dr Philip J Ayres Leeds Teaching Hospitals NHS Trust
Dr Paul Collinson St George’s Hospital, London
Dr Barry Cookson Public Health Laboratory Service, Colindale
Professor David C CumberlandUniversity of Sheffield
Professor Adrian Dixon University of Cambridge
Mr Steve Ebdon-JacksonDepartment of Health
Mrs Maggie FitchettAssociation of Cytogeneticists,Oxford
Dr Peter Howlett Portsmouth Hospitals NHS Trust
Professor Alistair McGuire City University, London
Dr Andrew Moore Editor, Bandolier
Dr Peter Moore Science Writer, Ashtead
Professor Chris Price London Hospital Medical School
Dr William RosenbergUniversity of Southampton
Mr Tony Tester South BedfordshireCommunity Health Council
Dr Gillian Vivian Royal Cornwall Hospitals Trust
Dr Greg Warner General Practitioner,Hampshire
Current members
Health Technology Assessment 2000; Vol. 4: No. 15
53
Dr Sheila Adam*
Department of Health
Professor George FreemanCharing Cross & WestminsterMedical School, London
Dr Mike GillBrent & Harrow Health Authority
Dr Anne Ludbrook University of Aberdeen
Professor Theresa Marteau Guy’s, King’s & St Thomas’s School ofMedicine & Dentistry, London
Professor Catherine PeckhamInstitute of Child Health,London
Dr Connie Smith Parkside NHS Trust, London
Ms Polly ToynbeeJournalist
Professor Nick Wald University of London
Professor Ciaran WoodmanCentre for Cancer Epidemiology,Manchester
Population Screening Panel
Past members
Chair: Professor Sir John Grimley EvansRadcliffe Infirmary, Oxford
Mrs Stella Burnside Altnagelvin Hospitals Trust,Londonderry
Mr John Cairns University of Aberdeen
Professor Howard CuckleUniversity of Leeds
Dr Carol Dezateux Institute of Child Health,London
Mrs Anne Dixon-Brown NHS Executive Eastern
Professor Dian Donnai St Mary’s Hospital, Manchester
Dr Tom Fahey University of Bristol
Mrs Gillian Fletcher National Childbirth Trust
Dr JA Muir Gray National ScreeningCommittee, NHS ExecutiveOxford
Professor Alexander Markham St James’s University Hospital, Leeds
Dr Ann McPherson General Practitioner, Oxford
Dr Susan Moss Institute of Cancer Research
Mr John Nettleton Consumer member
Mrs Julietta Patnick NHS Cervical Screening Programme,Sheffield
Dr Sarah Stewart-Brown Health Service Research Unit,University of Oxford
Current members
continued
* Previous Chair
Professor Michael Rawlins*
University of Newcastle-upon-Tyne
Dr Colin Bradley University of Birmingham
Professor AlasdairBreckenridge RDRD, Northwest Regional Health Authority
Ms Christine Clark Hope Hospital, Salford
Mrs Julie Dent Ealing, Hammersmith &Hounslow Health Authority,London
Mr Barrie Dowdeswell Royal Victoria Infirmary, Newcastle-upon-Tyne
Dr Tim Elliott Department of Health
Dr Desmond Fitzgerald Mere, Bucklow Hill, Cheshire
Professor Keith Gull University of Manchester
Dr Keith Jones Medicines Control Agency
Dr John Posnett University of York
Dr Tim van Zwanenberg Northern Regional Health Authority
Dr Kent Woods RDRD, Trent RO, Sheffield
Pharmaceutical Panel
Past members
Chair: Professor Tom WalleyUniversity of Liverpool
Dr Felicity Gabbay Transcrip Ltd
Dr Peter Golightly Drug Information Services,NHS Executive Trent
Dr Alastair Gray Health Economics Research Centre, University of Oxford
Professor Rod Griffiths NHS Executive West Midlands
Mrs Jeanette Howe Department of Health
Professor Trevor Jones ABPI, London
Ms Sally Knight Lister Hospital, Stevenage
Dr Andrew MortimoreSouthampton & SW HantsHealth Authority
Mr Nigel Offen NHS Executive Eastern
Dr John Reynolds The Oxford Radcliffe Hospital
Mrs Marianne Rigge The College of Health, London
Mr Simon Robbins Camden & Islington Health Authority, London
Dr Frances Rotblat Medicines Control Agency
Dr Eamonn Sheridan St James’s University Hospital,Leeds
Mrs Katrina Simister National Prescribing Centre,Liverpool
Dr Ross Taylor University of Aberdeen
Current members
Health Technology Assessment panel membership
54
Primary and Community Care Panel
Chair: Dr John TrippRoyal Devon & ExeterHealthcare NHS Trust
Mr Kevin Barton East London & City Health Authority
Professor John Bond University of Newcastle-upon-Tyne
Dr John Brazier University of Sheffield
Ms Judith Brodie Cancer BACUP
Mr Shaun Brogan Ridgeway Primary Care Group,Aylesbury
Mr Joe Corkill National Association for Patient Participation
Dr Nicky Cullum University of York
Professor Pam EnderbyUniversity of Sheffield
Dr Andrew FarmerInstitute of Health Sciences,Oxford
Dr Jim FordDepartment of Health
Professor Richard HobbsUniversity of Birmingham
Professor Allen HutchinsonUniversity of Sheffield
Dr Aidan MacFarlaneIndependent Consultant
Professor David Mant Institute of Health Sciences,Oxford
Dr Chris McCall General Practitioner, Dorset
Dr Robert Peveler University of Southampton
Professor Jennie PopayUniversity of Salford
Dr Ken Stein North & East Devon Health Authority
Current members
continued
Professor Angela Coulter*
King’s Fund, London
Professor Martin Roland*
University of Manchester
Dr Simon Allison University of Nottingham
Professor Shah Ebrahim Royal Free Hospital, London
Ms Cathy Gritzner King’s Fund, London
Professor Andrew Haines RDRD, North Thames Regional Health Authority
Dr Nicholas Hicks Oxfordshire Health Authority
Mr Edward Jones Rochdale FHSA
Professor Roger Jones Guy’s, King’s & St Thomas’sSchool of Medicine & Dentistry, London
Mr Lionel Joyce Chief Executive, Newcastle City Health NHS Trust
Professor Martin Knapp London School of Economics & Political Science
Dr Phillip Leech Department of Health
Professor Karen Luker University of Liverpool
Dr Fiona Moss Thames Postgraduate Medical& Dental Education
Professor Dianne Newham King’s College London
Professor Gillian Parker University of Leicester
Dr Mary Renfrew University of Oxford
Ms Hilary Scott Tower Hamlets Healthcare NHS Trust, London
Past members
* Previous Chair
Health Technology Assessment 2000; Vol. 4: No. 15
55
National Coordinating Centre for Health Technology Assessment, Advisory Group
Chair: Professor John GabbayWessex Institute for HealthResearch & Development
Dr Sheila Adam Department of Health
Professor Nicholas Black London School of Hygiene and Tropical Medicine
Professor Martin BuxtonHealth Economics Research Group, Brunel University
Mr Harry CaytonAlzheimer’s Disease Society
Professor Angela CoulterThe King’s Fund, London
Professor Paul DieppeMRC Health Services Research Collaboration,University of Bristol
Professor MikeDrummond Centre for Health Economics, University of York
Professor Shah EbrahimMRC Health Services Research Collaboration,University of Bristol
Ms Lynn Kerridge Wessex Institute for HealthResearch & Development
Professor Jos Kleijnen NHS Centre for Reviews and Dissemination, University of York
Dr Ruairidh Milne Wessex Institute for HealthResearch & Development
Ms Kay Pattison Research &Development Directorate, NHS Executive
Professor James Raftery Health Economics Unit, University of Birmingham
Professor Ian RussellDepartment of Health Sciences & Clinical Evaluation, University of York
Dr Ken Stein North & East Devon Health Authority
Professor Andrew Stevens Department of Public Health & Epidemiology, University of Birmingham
Professor Kent WoodsDepartment of Medicine & Therapeutics, University of Leicester
Current members
Dr Paul Roderick Wessex Institute for HealthResearch & Development
Past member
Professor Ian Russell*Department of Health Sciences & Clinical Evaluation, University of York
Professor Charles Florey*
Department of Epidemiology & Public Health, Ninewells Hospital & Medical School, University of Dundee
Professor David Cohen Professor of Health Economics, University of Glamorgan
Mr Barrie Dowdeswell Chief Executive, Royal Victoria Infirmary,Newcastle-upon-Tyne
Dr Michael Horlington Head of Corporate Licensing,Smith & Nephew GroupResearch Centre
Professor Sir Miles Irving Professor of Surgery, University of Manchester, Hope Hospital, Salford
Professor Martin Knapp Director, Personal Social ServicesResearch Unit, London School of Economics & Political Science
Professor Theresa Marteau Director, Psychology & Genetics Research Group, Guy’s, King’s & St Thomas’sSchool of Medicine & Dentistry, London
Professor Sally McIntyre MRC Medical Sociology Unit,Glasgow
Professor David Sackett Centre for Evidence Based Medicine, Oxford
Dr David Spiegelhalter MRC Biostatistics Unit, Institute of Public Health,Cambridge
Professor David Williams Department of Clinical Engineering, University of Liverpool
Dr Mark Williams Public Health Physician, Bristol
* Previous Chair
HTA Commissioning Board
Past members
Chair: Professor Shah EbrahimProfessor of Epidemiology of Ageing, University of Bristol
Professor Doug Altman Director, ICRF Medical Statistics Group, Centre forStatistics in Medicine, University of Oxford
Professor John BondDirector, Centre for HealthServices Research, University ofNewcastle-upon-Tyne
Mr Peter Bower General Manager andIndependent Health Advisor,Thames Valley Primary Care Agency
Ms Christine Clark Honorary Research Pharmacist, Hope Hospital, Salford
Professor Martin Eccles Professor of Clinical Effectiveness, University of Newcastle-upon-Tyne
Dr Mike Gill Regional Director of Public Health, NHS Executive South East
Dr Alastair Gray Director, Health EconomicsResearch Centre, University of Oxford
Professor Mark HaggardDirector, MRC Institute of Hearing Research, University of Nottingham
Dr Jenny Hewison Senior Lecturer, Department of Psychology,University of Leeds
Professor Alison Kitson Director, Royal College of Nursing Institute
Dr Donna Lamping Senior Lecturer, Department of Public Health,London School of Hygiene &Tropical Medicine
Professor Alan MaynardJoint Director, York HealthPolicy Group, University of York
Professor David Neal Joint Director, York HealthPolicy Group, University of York
Professor Jon Nicholl Director, Medical Care Research Unit, University of Sheffield
Professor Gillian Parker Nuffield Professor ofCommunity Care, University of Leicester
Dr Tim Peters Reader in Medical Statistics,Department of Social Medicine,University of Bristol
Professor Martin SeversProfessor in Elderly Health Care, University of Portsmouth
Dr Sarah Stewart-BrownHealth Service Research Unit,University of Oxford
Professor Ala Szczepura Director, Centre for Health Services Studies, University of Warwick
Dr Gillian Vivian Consultant, Royal CornwallHospitals Trust
Professor Graham WattDepartment of GeneralPractice, University of Glasgow
Professor Kent WoodsProfessor of Therapeutics,University of Leicester
Dr Jeremy Wyatt Senior Fellow, Health Knowledge Management Centre, University College London
Current members
Copies of this report can be obtained from:
The National Coordinating Centre for Health Technology Assessment,Mailpoint 728, Boldrewood,University of Southampton,Southampton, SO16 7PX, UK.Fax: +44 (0) 23 8059 5639 Email: hta@soton.ac.ukhttp://www.ncchta.org ISSN 1366-5278
Health Technology Assessm
ent 2000;Vol.4:No.15
Prophylactic removal of w
isdom teeth
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