Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth

Review question

We carried out this review, through Cochrane Oral Health, to find out whether impacted wisdom teeth in teenagers or adults should be removed if they are not causing any problems or they should be left alone and checked at regular intervals. This is an update of a review first published in 2012 and first updated in 2016.

Background

Wisdom teeth (also known as third molars) generally erupt between the ages of 17 and 26 years. They are the last teeth to come in, and normally erupt into a position closely behind the last standing teeth (second molars). Space for wisdom teeth can be limited and so they often fail to erupt or erupt only partially, because of impaction of the wisdom teeth against the teeth directly in front. In most cases, this occurs when second molars are blocking the path of eruption of third molar teeth and act as a physical barrier, preventing complete eruption. An impacted wisdom tooth is called 'asymptomatic' and 'disease-free' if there are no signs or symptoms of disease affecting the wisdom tooth or nearby structures.

Impacted wisdom teeth can cause swelling and ulceration of the gums around the wisdom teeth, damage to the roots of second molars, decay in second molars, gum and bone disease around second molars and development of cysts or tumours. It is generally agreed that removing wisdom teeth is appropriate if signs or symptoms of disease related to the wisdom teeth are present, but there is less agreement about how asymptomatic disease-free impacted wisdom teeth should be managed.

Study characteristics

The Cochrane Oral Health Information Specialist searched the medical literature up to 10 May 2019. We found two studies, one where the participants had been randomly chosen to have their wisdom teeth removed or not (a randomised controlled trial or RCT), and one where the study authors examined people who have opted themselves to either retain or remove their wisdom teeth (a prospective cohort study). The studies involved 493 people. The RCT was conducted at a dental hospital in the UK and included 77 adolescent male and female participants who had completed treatment with braces. The cohort study was conducted at a private dental clinic in the USA and involved 416 men aged 24 to 84 years who volunteered to take part.

Key results

The available evidence is insufficient to tell us whether or not asymptomatic disease-free impacted wisdom teeth should be removed.

The included studies did not measure health-related quality of life, costs or side effects of taking teeth out.

One study (the cohort study), which was at serious risk of bias, found that keeping asymptomatic disease-free impacted wisdom teeth in the mouth may increase the risk of gum infection (periodontitis) affecting the adjacent second molar in the long term, but this evidence was very uncertain. In the same study, the evidence was insufficient to draw any conclusions about the effect on the risk of caries in the adjacent second molar.

The other study (the RCT) was also at high risk of bias. It measured crowding of the teeth in the mouth, and found that this may not be significantly affected by whether impacted wisdom teeth are kept in the mouth or removed.

Quality of the evidence

We assessed the evidence provided by the two studies to be low to very low certainty, so we cannot rely on these findings. High-quality research is urgently needed to support clinical practice in this area.

Conclusion

There is a lack of scientific evidence on which dental health professionals and policy makers can base treatment decisions for asymptomatic disease-free impacted wisdom teeth. Dental professionals will therefore be guided by clinical expertise and local or national clinical guidance, taking patient preferences into account. Where asymptomatic disease-free impacted wisdom teeth are not removed, monitoring by a dental health professional at regular intervals will help identify and address any problems that may develop.

Authors' conclusions: 

Insufficient evidence is available to determine whether asymptomatic disease-free impacted wisdom teeth should be removed or retained. Although retention of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is very low certainty. Well-designed RCTs investigating long-term and rare effects of retention and removal of asymptomatic disease-free impacted wisdom teeth, in a representative group of individuals, are unlikely to be feasible. In their continuing absence, high quality, long-term prospective cohort studies may provide valuable evidence in the future. Given the current lack of available evidence, patient values should be considered and clinical expertise used to guide shared decision-making with people who have asymptomatic disease-free impacted wisdom teeth. If the decision is made to retain these teeth, clinical assessment at regular intervals to prevent undesirable outcomes is advisable.

Read the full abstract...
Background: 

Prophylactic removal of asymptomatic disease-free impacted wisdom teeth is the surgical removal of wisdom teeth in the absence of symptoms and with no evidence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease (periodontitis), caries and the development of cysts and tumours. When surgical removal is performed in older people, the risk of postoperative complications, pain and discomfort is increased. Other reasons to justify prophylactic removal of asymptomatic disease-free impacted third molars have included preventing late lower incisor crowding, preventing damage to adjacent structures such as the second molar or the inferior alveolar nerve, in preparation for orthognathic surgery, in preparation for radiotherapy or during procedures to treat people with trauma to the affected area. Removal of asymptomatic disease-free wisdom teeth is a common procedure, and researchers must determine whether evidence supports this practice. This review is an update of an review originally published in 2005 and previously updated in 2012 and 2016.

Objectives: 

To evaluate the effects of removal compared with retention (conservative management) of asymptomatic disease-free impacted wisdom teeth in adolescents and adults.

Search strategy: 

Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 10 May 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2019, Issue 4), MEDLINE Ovid (1946 to 10 May 2019), and Embase Ovid (1980 to 10 May 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov)and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. .

Selection criteria: 

We included randomised controlled trials (RCTs), with no restriction on length of follow-up, comparing removal (or absence) with retention (or presence) of asymptomatic disease-free impacted wisdom teeth in adolescents or adults. We also considered quasi-RCTs and prospective cohort studies for inclusion if investigators measured outcomes with follow-up of five years or longer.

Data collection and analysis: 

Eight review authors screened search results and assessed the eligibility of studies for inclusion according to the review inclusion criteria. Eight review authors independently and in duplicate conducted the risk of bias assessments. When information was unclear, we contacted the study authors for additional information.

Main results: 

This review update includes the same two studies that were identified in our previous version of the review: one RCT with a parallel-group design, which was conducted in a dental hospital setting in the United Kingdom, and one prospective cohort study, which was conducted in the private sector in the USA.

Primary outcome

No eligible studies in this review reported the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth on health-related quality of life

Secondary outcomes

We found only low- to very low-certainty evidence of the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth for a limited number of secondary outcome measures.

One prospective cohort study, reporting data from a subgroup of 416 healthy male participants, aged 24 to 84 years, compared the effects of the absence (previous removal or agenesis) against the presence of asymptomatic disease-free impacted wisdom teeth on periodontitis and caries associated with the distal aspect of the adjacent second molar during a follow-up period of three to over 25 years. Very low-certainty evidence suggests that the presence of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting the adjacent second molar in the long term. In the same study, which is at serious risk of bias, there is insufficient evidence to demonstrate a difference in caries risk associated with the presence or absence of impacted wisdom teeth.

One RCT with 164 randomised and 77 analysed adolescent participants compared the effect of extraction with retention of asymptomatic disease-free impacted wisdom teeth on dimensional changes in the dental arch after five years. Participants (55% female) had previously undergone orthodontic treatment and had 'crowded' wisdom teeth. No evidence from this study, which was at high risk of bias, was found to suggest that removal of asymptomatic disease-free impacted wisdom teeth has a clinically significant effect on dimensional changes in the dental arch.

The included studies did not measure any of our other secondary outcomes: costs, other adverse events associated with retention of asymptomatic disease-free impacted wisdom teeth (pericoronitis, root resorption, cyst formation, tumour formation, inflammation/infection) and adverse effects associated with their removal (alveolar osteitis/postoperative infection, nerve injury, damage to adjacent teeth during surgery, bleeding, osteonecrosis related to medication/radiotherapy, inflammation/infection).

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