Day: January 6, 2020

What are Indications for Wisdom Teeth Removal?

Patient Presentation
A 14-year-old female came to clinic for her health supervision visit. Her mother was concerned because the patient was scheduled to have her wisdom teeth out as part of planned orthodontic treatment. “In my home country we don’t take teeth out very much. Only if they are rotten. We also have alot more rotten teeth too,” the mother stated. The past medical and family history were non-contributory including no problems with anesthesia.

The pertinent physical exam showed a healthy female with normal vital signs with her height and weight in the 25-50%. She had an obvious malalignment of multiple teeth. The rest of her examination was normal. The diagnosis of a healthy female was made. The pediatrician recommended that the mother discuss the procedure with their dentist, orthodontist and dental surgeon so she would better understand the reasons they were recommending the dental extraction.

Discussion
Third molars (M3) are often referred to as wisdom teeth. They begin calcification at 7-9 years and usually erupt between 17-26 years. They usually erupt behind the second molar into what may be limited space. M3 can also fail to erupt. Impacted M3 occur because of abnormal position, obstruction, or lack of space.

There are 4 potential groups to consider for M3 management:

  • Group 1 – symptomatic with clinical disease
    • Epidemiology: common
    • Clinical presentations: edema, pain, trismus
    • Disease: caries, pericoronitis and infection are common
    • Treatment: treatment of disease is important but extraction is recommended because patient is symptomatic and has clinical disease
  • Group 2 – symptomatic without clinical disease
    • Epidemiology: doesn’t occur frequently and hard to discern
    • Clinical presentations: vague pain
    • Treatment: Discussion with patient regarding risks and benefits of symptoms that may or may not be attributable to M3
  • Group 3 – asymptomatic with clinical disease
    • Clinical presentations: none
    • Disease: caries, periodonitis, cysts or tumors
    • Treatment: treatment of disease is important but extraction is often recommended because patient has clinical disease

  • Group 4 – asymptomatic without clinical disease
    • Epidemiology: often occurs depending on age
    • Clinical presentations: none
    • Treatment: Controversial, “Available evidence is insufficient to show whether or not asymptomatic disease-free impacted wisdom teeth should be removed.”

Learning Point

Some problems associated with M3 and potential indications for removal include:

  • Gum disease with edema or ulceration
  • Bone disease including cysts or tumors, fractures
  • Damage to adjacent structures – e.g. roots of adjacent teeth
  • Infection – localized or adjacent
  • Spacing problems for arch and dental structures – orthodontic or orthognathic surgical indications
  • Non-functional, non-hygenic tooth
  • Interference with removable prosthetics (e.g. dentures)

Potential problems with M3 surgical removal include:

  • Bleeding
  • Cost
  • Fracture
  • Osteitis or other infections
  • Nerve injury
  • Periodontal defects

M3 that are asymptomatic without clinical disease often over time are removed because they do develop disease. About 30% of these asymptomatic, unerupted M3 will move over time and cause problems. Thirty to sixty percent of patients who initially retained their M3 have them extracted between 4-12 years later. There is also little evidence for or against active surveillance for potential future disease in asymptomatic non-diseased M3. Complications of surgical removal once disease begins includes more difficulty in treating the disease, spread of disease to adjacent dental or facial structures, and increased risks of complications with surgical removal of M3s.

The first and second molar also have indications for their removal which can be reviewed in the to Learn More section below.

Questions for Further Discussion
1. When should infants and young children have their first dental visit?
2. When should children receive fluoride treatments for their teeth or sealants?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tooth Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Hatami A, Dreyer C. The extraction of first, second or third permanent molar teeth and its effect on the dentofacial complex. Aust Dent J. August 2019. doi:10.1111/adj.12716

Steed MB. The indications for third-molar extractions. J Am Dent Assoc 1939. 2014;145(6):570-573. doi:10.14219/jada.2014.18

Dodson TB, Susarla SM. Impacted wisdom teeth. BMJ Clin Evid. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4148832/. Accessed October 7, 2019.

Ghaeminia H, Perry J, Nienhuijs MEL, et al. Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth. Cochrane Database Syst Rev. 2016;(8):CD003879. doi:10.1002/14651858.CD003879.pub4

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa