prophylactic removal of wisdom teeth

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

Copyright notice

© Queen's Printer and Controller of HMSO 2001 HTA reports may be freely reproduced for the purposes of private research and study and may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising Violations should be reported to [email protected] Applications for commercial reproduction should be addressed to HMSO, The Copyright Unit, St Clements House, 2–16 Colegate, Norwich NR3 1BQ

© Queen's Printer and Controller of HMSO

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

How to obtain copies of this and other HTA Programme reports.An electronic version of this publication, in Adobe Acrobat format, is available for downloading free ofcharge for personal use from the HTA website (http://www.hta.ac.uk). A fully searchable CD-ROM isalso available (see below).

Printed copies of HTA monographs cost £20 each (post and packing free in the UK) to both public andprivate sector purchasers from our Despatch Agents.

Non-UK purchasers will have to pay a small fee for post and packing. For European countries the cost is£2 per monograph and for the rest of the world £3 per monograph.

You can order HTA monographs from our Despatch Agents:

– fax (with credit card or official purchase order) – post (with credit card or official purchase order or cheque)– phone during office hours (credit card only).

Additionally the HTA website allows you either to pay securely by credit card or to print out yourorder and then post or fax it.

Contact details are as follows:HTA Despatch Email: [email protected]/o Direct Mail Works Ltd Tel: 02392 492 0004 Oakwood Business Centre Fax: 02392 478 555Downley, HAVANT PO9 2NP, UK Fax from outside the UK: +44 2392 478 555

NHS libraries can subscribe free of charge. Public libraries can subscribe at a very reduced cost of £100 for each volume (normally comprising 30–40 titles). The commercial subscription rate is £300 per volume. Please see our website for details. Subscriptions can only be purchased for the current orforthcoming volume.

Payment methods

Paying by chequeIf you pay by cheque, the cheque must be in pounds sterling, made payable to Direct Mail Works Ltdand drawn on a bank with a UK address.

Paying by credit cardThe following cards are accepted by phone, fax, post or via the website ordering pages: Delta, Eurocard,Mastercard, Solo, Switch and Visa. We advise against sending credit card details in a plain email.

Paying by official purchase orderYou can post or fax these, but they must be from public bodies (i.e. NHS or universities) within the UK.We cannot at present accept purchase orders from commercial companies or from outside the UK.

How do I get a copy of HTA on CD?

Please use the form on the HTA website (www.hta.ac.uk/htacd.htm). Or contact Direct Mail Works (seecontact details above) by email, post, fax or phone. HTA on CD is currently free of charge worldwide.

The website also provides information about the HTA Programme and lists the membership of the variouscommittees.

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.

Criteria for inclusion in the HTA monograph series Reports are published in the HTA monograph series if (1) they have resulted from work either prioritised by theStanding Group on Health Technology, or otherwise commissioned for the HTA programme, and (2) they are ofa sufficiently high scientific quality as assessed by the referees and editors.

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: [email protected]://www.ncchta.org


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


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


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


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


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.


5

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


7

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


9

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


11

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.


13

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


15

1. Department of Health. Hospital Episode Statistics.England: financial year 1994–5 Volume I: finishedconsultant episodes by diagnosis and operativeprocedure. Prepared by the Government StatisticalService, Crown Copyright, London, 1996.

2. Landes DP. The relationship between dental healthand variations in the level of third molar removalsexperienced by populations. Community Dent Health1998;15:67–71.

3. Shepherd J, Brickley M. Surgical removal of thirdmolars. Prophylactic surgery should be abandoned.BMJ 1994;309:620–1.

4. Toth B. The appropriateness of prophylacticextraction of impacted third molars. A review of theliterature. Bristol: Health Care Evaluation Unit,University of Bristol; 1993.

5. Gilthorpe MS, Bedi R. An exploratory studycombining hospital episode statistics with socio-demographic variables, to examine the access andutilisation of hospital oral surgery services.Community Dent Health 1997;14:209–13.

6. Lopes V, Mumenya R, Feinmann C, Harris M. Thirdmolar surgery: an audit of the indications forsurgery, post-operative complaints and patientsatisfaction. Br J Oral Maxillofac Surg 1995;33:33–5.

7. Brickley M, Shepherd J, Mancini G. Comparison ofclinical treatment decisions with US NationalInstitutes of Health consensus indications for lowerthird molar removal. Br Dent J 1993;175:102–5.

8. Brickley M, Shepherd J. Performance of a neuralnetwork trained to make third-molar treatment-planning decisions. Med Decis Making 1996;16:153–60.

9. Pratt CA, Hekmat M, Barnard JDW, Zaki GA.Indications for third molar surgery. J R Coll SurgJournal Edinb 1998;43:105–8.

10. Worrall S, Riden K, Haskell R, Corrigan A. UKNational Third Molar project: the initial report. BrJ Oral Maxillofac Surg 1998;36:14–18.

11. National Institutes of Health. NIH consensusdevelopment conference for removal of thirdmolars. J Oral Surg 1980;38:235–6.

12. Faculty of Dental Surgery. Current clinical practiceand parameters of care. The management ofpatients with third molar (syn: wisdom) teeth. London: The Royal College of Surgeons ofEngland; 1997.

13. Stephens R, Kogon S, Reid J. The unerupted orimpacted third molar – a critical appraisal of itspathologic potential. J Can Dent Assoc1989;55:201–7.

14. Ahlqwist M, Grondahl HG. Prevalence of impactedteeth and associated pathology in middle-aged andolder Swedish women. Community Dent OralEpidemiol 1991;19:116–19.

15. Mercier P, Precious D. Risks and benefits of removalof impacted third molars. A critical review of theliterature. J Oral Maxillofac Surg 1992;21:17–27.

16. Knutsson K, Brehmer B, Lysell L, Rohlin M.General dental practitioners’ evaluation of the need for extraction of asymptomaticmandibular third molars. Community Dent OralEpidemiol 1992;20:347–50.

17. Kostopoulou O, Brickley MR, Shepherd JP,Knutsson K, Rohlin M. Agreement between practi-tioners concerning removal of asymptomatic thirdmolars. Community Dent Health 1997;14:129–32.

18. Kostopoulou O, Brickley MR, Shepherd JP,Newcombe RG. Perceived risk of future pathologyassociated with pathology-free third molars: acomparison of oral and maxillofacial surgeons andfamily dentists. Br Dent J 2000;188:28–31.

19. Daley TD. Third molar prophylactic extraction: areview and analysis of the literature. Gen Dent1996;44:310–20.

20. Von-Wowern N, Nielsen HO. The fate of impactedlower third molars after the age of 20. Int J OralMaxillofac Surg 1989;18:277–80.

References

References

16

21. Lindqvist B, Thilander B. Extraction of third molarsin cases of anticipated crowding in the lower jaw.Am J Orthod 1982;81:130–9.

22. Vasir N, Robinson R. The mandibular third molarand late crowding of the mandibular incisors – a review. Br J Orthod 1991;18:59–66.

23. Song F, Landes D, Glenny A, Sheldon T.Prophylactic removal of impacted third molars: anassessment of published reviews. Br Dent J1997;182:339–46.

24. Harradine N, Pearson M, Toth B. The effect ofextraction of third molars on late lower incisorcrowding: a randomized controlled trial. Br J Orthod 1998;25:117–22.

25. Carmichael FA, McGowan DA. Incidence of nervedamage following third molar removal: a west ofScotland Oral Surgery Research Group Study. Br J Oral Maxillofac Surg 1992;30:78–82.

26. Brickley M, Kay E, Shepherd JP, Armstrong RA.Decision analysis for lower-third-molar surgery. MedDecis Making 1995;15:143–51.

27. Chiapasco M, Crescentini M, Romanoni G.Germectomy or delayed removal of mandibularimpacted third molars: the relationship betweenage and incidence of complications. J OralMaxillofac Surg 1995;53:418–22.

28. Larsen P. Alveolar osteitis after surgical removal ofimpacted third molars. Identification of the patientat risk. Oral Surg Oral Med Oral Pathol1992;73:393–7.

29. Vondeling H, Maningky M, Bezemer D, Smeele LE,Baart JA, van der Waal I. Issues in the design andpreliminary results of a randomized controlled trialcomparing the effects and costs of preventiveremoval of third molars versus removal onindication. In: 15th Annual Meeting of theISTAHC; 1999; Edinburgh, Scotland.

30. Anderson M. Removal of asymptomatic thirdmolars: indications, contraindications, risks andbenefits. J Indiana Dent Assoc 1998;77:41–6.

31. Bertrand G, Darque F, Duhart A-M, Le Petit X,Ohayon-Farouz R, Oriez D, et al. Question mise endiscussion. La dent de sagesse. Orthod Fr1989;1:371–429.

32. Bishara S. Third molars: a dilemma! Or is it? Am J Orthod Dentofacial Orthop 1999;115:628–33.

33. Bonetti GA, Prati C, Graziani E. Terzo molare:valutazione del ruolo, indicazioni alla estrazione.Dent Cadmos 1988;56:56–60.

34. Bramante MA. Controversies in orthodontics. DentClin North Am 1990;34:91–102.

35. Brokaw WD. The third molar question: when andwhy should we recommend removal? Va Dent J1991;68:18–21.

36. Cade T. Paresthesia of the inferior alveolar nervefollowing the extraction of the mandibular thirdmolars: a literature review of its causes, treatment,and prognosis. Milit Med 1992;157:389–92.

37. Chikhani L, Cartier S, Elamrani K, Guilbert F.Lesions du nerf lingual au cours de l’extraction dela dent de sagesse mandibulaire. Rev Stomatol ChirMaxillofac 1994;95:369–73.

38. Dénes J, Dénes Z, Kaan M. Az impactaltbolcsessegfogak preventiv eltavolitasanak indikacioi.Fogorv Sz 1993;86:227–30.

39. ECRI. Removal of third molars. ECRI; 1993.

40. Flick W. The third molar controversy: framing thecontroversy as a public health policy issue. J OralMaxillofac Surg 1999;57:438–44.

41. Forssel H, Miettinen J. Alaviisaudenhampaanpoistoindikaatiot. Suom Hammaslaakarilehti1988;35:1078–81.

42. Garattini G, Grecchi MT, Vogel G. Ruolo dei terzimolari inferiori nell’insorgenza di malocclusionidentarie: revisione della letteratura. Mondo Ortod1990;15:145–50.

43. Goia F, Gilardino M, Cappella M, Bruno GB. Terzomolare: valutazioni ed indicazioni all’estrazione dalpunto di vista ortodontico. Minerva Ortognatod1990;8:135–8.

44. Jaquiéry C, Pajarola GF, Sailer HF, Lambrecht JT.L’extraction chirurgicale des dents de sagesseinferieures (I). Indications et diagnosticspreoperatoires. Rev Mensuelle Suisse Odontostomatol1994;104:1511–19.

45. Kugelberg C. Third molar surgery. Curr Opin Dent1992;2:9–16.

46. Lechien P. Faut-il ou non extraire les dentsincluses? Rev Belg Med Dent 1995;50:29–39.


17

47. Mommaerts M, Jacobs W. La lesion du nerf linguallors de l’extraction des dents de sagesse inferieures.Rev Belg Med Dent 1991;46:27–46.

48. Peterson LJ. Rationale for removing impactedteeth: when to extract or not to extract. J Am DentAssoc 1992;123:198–204.

49. Robinson R, Vasir N. The great eights debate: do themandibular third molars affect incisor crowding? A review of the literature. Dent Update 1993;20:242–6.

50. Robinson P. The impacted lower wisdom tooth: toremove or to leave alone? Dent Update 1994;21:245–8.

51. Sands T, Pynn B, Nenniger S. Third molar surgery:current concepts and controversies. Part 2. OralHealth 1993;83:19–30.

52. Sands T, Pynn B, Nenniger S. Third molar surgery:current concepts and controversies. Part 1. OralHealth 1993;83:11–18.

53. Southard T. Third molars and incisor crowding:when removal is unwarranted.J Am Dent Assoc 1992;123:75–9.

54. Tate TE. Impactions: observe or treat? J Ca DentAssoc 1994;22:59–64.

55. Tealdi R, Domini R. Indicazioni all’estrazione delterzo molare incluso nella programmazione deltrattamento ortodontico. Rassegna della letteratura.Minerva Stomatol 1986;35:461-3.

56. Torres JH. Benefices et risques des avulsions dedents de sagesse. Rev Stomatol Chir Maxillofac1997;98:173–8.

57. van der Linden W, Lownie J, Cleaton-Jones P.Should impacted third molars be removed? A review of the literature. J Dent Assoc S Afr1993;48:235–40.

58. Waite P, Reynolds R. Surgical management ofimpacted third molars. Semin Orthodont1998;4:113–23.

59. Weisenfeld M, Kondis S. Prophylactic removal ofimpacted third molars, revisited. Gen Dent1991;39:344–5.

60. Edwards M, Brickley M, Goodey R, Shepherd J. Thecost, effectiveness, and cost-effectiveness of removaland retention of asymptomatic, disease-free thirdmolars. Br Dent J 1999;187:380–4.

61. Tulloch J, Antczak-Bouckoms A. Decision analysis inthe evaluation of clinical strategies for themanagement of mandibular third molars. J DentEduc 1987;51:652–60.

62. Tulloch J, Antczak-Bouckoms A, Ung N. Evaluation of the costs and relative effectiveness ofalternative strategies for the removal of mandibularthird molars. Int J Technol Assess Health Care1990;6:505–15.

63. Precious DS, Mercier P, Payette F. Risques etbenefices de l’ablation des troisieme molairesincluses: revue critique de la litterature – partie 1. J Assoc Dent Can 1992;58:756–9.

64. Precious DS, Mercier P, Payette F. Risques etbenefices de l’ablation des troisieme molairesincluses: revue critique de la litterature – partie 2. J Assoc Dent Can 1992;58:845–52.

65. Svendsen H. Visdomstaender – skal vi leve meddem eller af dem? Tandlaegernes Nye Tidsskrift1990;5:340–3.

66. Alling C, Catone G. Management of impactedteeth. J Oral Maxillofac Surg 1993;51:3–6.

67. Anker A. What is the future of third molar removal?A critical review of the need for the removal ofthird molars. Ann R Australas Coll Dent Surg1996;13:154–7.

68. Benauwt A, Charron C, Dahan J, Philippe J, Saint-Blancat C. Les dents de sagesse. Argumentations dela question mise en discussion. Orthodont Fr1989;2:799–814.

69. Bakos L, Pyle G. Odontogenic keratocyst involvingimpacted mandibular third molars. Gen Dent1991;39:163–4.

70. Camplin A. Kaj narediti z retiniranim zobom?Zobozdrav Vestn 1987;2:68–70.

71. Commissionat Y, Roisin-Chausson MH. Lesions dunerf alveolaire inferieur au cours de l’extractiondes dents de sagesse. Rev Stomatol Chir Maxillofac1995;96:385–91.

72. Cooper-Newland D. Management of impacted thirdmolar teeth. J Gt Houst Dent Soc 1996;67:10–12.

73. Di Gianfilippo C, Giannoni M, Chimenti C, BaldiM, Mura P. Rimozione dei denti inclusi: indicazionie controindicazioni. Dent Cadmos 1990;58:50–4.

References

18

74. Garattini G, Sacilotto G, Strohmenger L, Valsasina A, Weinstein R. Germectomia dei terzimolari inferiori: indicazioni e controindicazioni.Dent Cadmos 1988;56:40–4.

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)


19

Appendix 1

Search strategies


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


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


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


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


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


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


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


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


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


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


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

%


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


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


45

TABLE 5 contd Studies excluded from the review


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


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


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


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


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


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: [email protected]://www.ncchta.org ISSN 1366-5278

Health Technology Assessm

ent 2000;Vol.4:No.15

Prophylactic removal of w

isdom teeth

FeedbackThe HTA programme and the authors would like to know

your views about this report.

The Correspondence Page on the HTA website(http://www.ncchta.org) is a convenient way to publish

your comments. If you prefer, you can send your comments to the address below, telling us whether you would like

us to transfer them to the website.

We look forward to hearing from you.

prophylactic removal of wisdom teeth

Documents

professor of professor

professor richard lilford

psychology health

clinical reader

clinical pharmacology

psychological medicine

standing group

hospital medical school