Prophylactic removal of impacted mandibular third molars: a systematic review and economic evaluation

Abstract

<jats:sec id="abs1-1"> <jats:title>Background</jats:title> <jats:p>Impacted third molars are third molars that are blocked, by soft tissue or bone, from fully erupting through the gum. This can cause pain and disease. The treatment options for people with impacted third molars are removal or retention with standard care. If there are pathological changes, the current National Institute for Health and Care Excellence guidance states that the impacted third molar should be removed.</jats:p> </jats:sec> <jats:sec id="abs1-2"> <jats:title>Objective</jats:title> <jats:p>The objective of this study was to appraise the clinical effectiveness and cost-effectiveness of the prophylactic removal of impacted mandibular third molars compared with retention of, and standard care for, impacted third molars.</jats:p> </jats:sec> <jats:sec id="abs1-3"> <jats:title>Methods</jats:title> <jats:p>Five electronic databases were searched (1999 to 29 April 2016) to identify relevant evidence [The Cochrane Library (searched 4 April 2016 and 29 April 2016), MEDLINE (searched 4 April 2016 and 29 April 2016), EMBASE (searched 4 April 2016 and 29 April 2016), EconLit (searched 4 April 2016 and 29 April 2016) and NHS Economic Evaluation Database (searched 4 April 2016)]. Studies that compared the prophylactic removal of impacted mandibular third molars with retention and standard care or studies that assessed the outcomes from either approach were included. The clinical outcomes considered were pathology associated with retention, post-operative complications following extraction and adverse effects of treatment. Cost-effectiveness outcomes included UK costs and health-related quality-of-life measures. In addition, the assessment group constructed a de novo economic model to compare the cost-effectiveness of a prophylactic removal strategy with that of retention and standard care.</jats:p> </jats:sec> <jats:sec id="abs1-4"> <jats:title>Results</jats:title> <jats:p>The clinical review identified four cohort studies and nine systematic reviews. In the two studies that reported on surgical complications, no serious complications were reported. Pathological changes due to retention of asymptomatic impacted mandibular third molars were reported by three studies. In these studies, the extraction rate for retained impacted mandibular third molars varied from 5.5% to 31.4%; this variation can be explained by the differing follow-up periods (i.e. 1 and 5 years). The findings from this review are consistent with the findings from previous systematic reviews. Two published cost-effectiveness studies were identified. The authors of both studies concluded that, to their knowledge, there is currently no economic evidence to support the prophylactic removal of impacted mandibular third molars. The results generated by the assessment group’s lifetime economic model indicated that the incremental cost-effectiveness ratio per quality-adjusted life-year gained for the comparison of a prophylactic removal strategy with a retention and standard care strategy is £11,741 for people aged 20 years with asymptomatic impacted mandibular third molars. The incremental cost per person associated with prophylactic extraction is £55.71, with an incremental quality-adjusted life-year gain of 0.005 per person. The base-case incremental cost-effectiveness ratio per quality-adjusted life-year gained was found to be robust when a range of sensitivity and scenario analyses were carried out.</jats:p> </jats:sec> <jats:sec id="abs1-5"> <jats:title>Limitations</jats:title> <jats:p>Limitations of the study included that no head-to-head trials comparing the effectiveness of prophylactic removal of impacted mandibular third molars with retention and standard care were identified with the assessment group model that was built on observational data. Utility data on impacted mandibular third molars and their symptoms are lacking.</jats:p> </jats:sec> <jats:sec id="abs1-6"> <jats:title>Conclusions</jats:title> <jats:p>The evidence comparing the prophylactic removal of impacted mandibular third molars with retention and standard care is very limited. However, the results from an exploratory assessment group model, which uses available evidence on symptom development and extraction rates of retained impacted mandibular third molars, suggest that prophylactic removal may be the more cost-effective strategy.</jats:p> </jats:sec> <jats:sec id="abs1-7"> <jats:title>Future work</jats:title> <jats:p>Effectiveness evidence is lacking. Head-to-head trials comparing the prophylactic removal of trouble-free impacted mandibular third molars with retention and watchful waiting are required. If this is not possible, routine clinical data, using common definitions and outcome reporting methods, should be collected.</jats:p> </jats:sec> <jats:sec id="abs1-8"> <jats:title>Study registration</jats:title> <jats:p>This study is registered as PROSPERO CRD42016037776.</jats:p> </jats:sec> <jats:sec id="abs1-9"> <jats:title>Funding</jats:title> <jats:p>This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in <jats:italic>Health Technology Assessment</jats:italic>; Vol. 24, No. 30. See the NIHR Journals Library website for further project information.</jats:p> </jats:sec>

Can anxiety in third molar surgeries with different degrees of difficulty and extent interfere with the perception of postoperative pain and trismus?—An observational and prospective study

“…The findings of the present study did not confirm this eventual statement, although pain was strongly associated with this condition (trismus), especially until the fifth postoperative day (day 5). Trismus has been associated with extractions of 3Ms, as well as, surgical time and complexity of the procedure and also with development of infection and dry socket (22,23). The current study corroborates the findings in the literature regarding association between trismus and the length of the procedure, as well as, observes that the operator's perception of the surgery complexity is also associated with a greater reduction in mouth opening.…”

“…Third molar extraction is one of the most common invasive procedures in dentistry (21) and, in these procedures, patients may experience discomfort, restriction in daily activities and, in addition, patients may experience postoperative complications such as pain and trismus, among others (22,23). In this observational and prospective clinical trial, it was sought to know the effect and interaction produced by dental anxiety in postoperative pain and trismus following 3Ms extractions with different degrees of difficulty and extension, giving to this study a clear differential, since standardization with similar procedures has been the rule in this type evaluation in the current literature.…”

Impact of the presence of partially erupted third molars on the local radiographic bone condition

“…Some studies elucidate reasons to indicate 3M removal, such as caries, periodontitis, and pain 1 , 2 , 5 , 16 , 17 . A current systematic review concluded that the evidence comparing the prophylactic removal of impacted lower 3M with its retention is very limited 18 . Although sufficient evidence is lacking, the authors suggest that prophylactic removal may be the most cost-effective strategy 18 .…”

“…A current systematic review concluded that the evidence comparing the prophylactic removal of impacted lower 3M with its retention is very limited 18 . Although sufficient evidence is lacking, the authors suggest that prophylactic removal may be the most cost-effective strategy 18 . However, these results are related to impacted teeth and systematic reviews evaluating the effectiveness of removing partially erupted teeth were not found.…”

Subcutaneous Emphysema Caused by Third Molar Extraction

“…The subcutaneous emphysema possibly developed when the right mandibular, semi-impacted, horizontally placed third molar was extracted after sectioning using an air-turbine handpiece 2 days before CT imaging; the extraction was performed before C-ion RT to ease oral care following irradiation to the head and neck region, as food impaction was likely to occur under the mucosa overlying the semi-impacted tooth. 1 The blue arrow indicates the socket from which the third molar was extracted ( Figure 2 ). In this case, it is probable that when the mucoperiosteal flap formed and the third molar was sectioned with an air-turbine handpiece, air invaded the soft tissues from the mucoperiosteal flap 2 and spread to the parapharyngeal space ( Figure 4 ).…”