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To extract or not?
THE BIG PICTURE To extract or not? Background.—The most common oral surgery procedure is the removal of impacted molars. Between 18% and 40% of all molars extracted are without symptoms, and there is a lack of consensus regarding management. Surgeons tend to either choose a conservative approach that leaves the tooth in place until pathologic conditions develop or a prophylactic approach that intervenes to avoid morbidity associated with tooth extraction. Impacted third molars may be left in place to reduce the risk of damaging the inferior alveolar or lingual nerves. The paresthesia (probably caused by neuropraxia) or anesthesia (probably caused by axonotmesis) accompanying removal is usually limited but can last for some time. Pericoronitis is the most common problem that develops in mandibular third molars, but few longitudinal studies provide insight into all the pathologic processes that develop in tooth impaction. Each professional has been free to use an intuitive and somewhat arbitrary approach to these cases. The most relevant factors in making the decision are patient information, characteristics of the dental impaction, and existing clinical and scientific evidence relevant to the situation. However, authors have also identified examiner preferences based on specialty (general dentists versus oral surgeons), number of molars proposed for removal, socioeconomic level of the population, patient oral hygiene, public expenditure on oral health, and conservative or interventional inclination of the dental school providing training. A descriptive observational study sought to add to the literature guiding management of asymptomatic impacted third molars. Methods.—The 40 impacted lower third molars were without symptoms but the patients were seeking removal. Examiners completed questionnaires covering the decision to perform removal, degree of confidence in the indication for prophylactic removal, and estimated risk of developing pathologic conditions with no extraction. These conditions included cysts, pericoronitis, periodontal lesions, distal surface caries of the second molar, and root resorption of the second molar. In addition to the questionnaires, each molar was studied via orthopantomographs that were given to four professionals who had various levels of surgical experience. Results.—In 95% of the molars, removal was indicated, with a mean confidence level of 87.36%. Examiner
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Dental Abstracts
decision was significantly related to the estimated probability of pathology if extraction was not performed. The factors affecting the extraction decision were (in descending order of influence) estimated risk of complications, molar inclination, age, degree of impaction, and gender of patient. The evaluators showed no statistically significant differences in their decisions to extract or their estimated risk of complications relative to their experience. Prophylactic removal was likely chosen based on the clinical relevance of cyst formation or root resorption rather than on the actual prevalence of these complications. Oral surgeons tended to rely more heavily on the estimated risk of pericoronitis, whereas general dentists were more likely to be swayed by the estimated risk of periodontal lesions. The high estimated probability that any pathologic conditions would develop may be related to the fact that 70% of the teeth were found in patients under age 30 years. Professionals were inclined to remove distoangular molars with partial mucosal coverage in patients aged 19 to 25 years and horizontal teeth with partial or total mucosal coverage in patients aged 19 to 40 years. The risks of caries and periodontal damage with mesioangular and horizontal impaction were 48.42% and 60.76%, respectively. Root resorption of the second molar occurs in horizontal and mesioangular third molars with total bony coverage and was noted in 25% of the molars located in these positions; its estimated mean risk was 25.56%. Discussion.—The existing body of clinical and scientific evidence has provided the basis for determining the treatment of asymptomatic impacted third molars. Partial mucosal coverage tends to lead to infectious complications; mesioangular and horizontal positions are linked to caries, root resorption, and periodontal disorders of the distal surface of the second molar. Bacterial invasion is stymied by total mucosal and bony coverage. The partial retention of mucosal tissues yields a greater risk of complications. Patient age influences prognosis, with greater morbidity seen in older patients. The problems inherent to surgical removal can be minimized by taking care during tissue manipulation, giving analgesia and anti-inflammatory medication, and emphasizing patient adherence to the postoperative directions. The patient’s systemic condition should be carefully assessed to predict the development of bleeding and infectious complications.
Clinical Significance.—Reported here, the decision to extract, or not, otherwise asymptomatic impacted lower third molars, traditionally justified by claims of thwarting future morbidity, has apparently rested more on subjective appraisals than objective criteria. No long-term, controlled studies of extraction versus monitoring for these situations exist but are needed. How to design such a study is an ethical challenge.
Almendros-Marque´s N, Alaejos-Algarra E, Quinteros-Borgarello M, et al: Factors influencing the prophylactic removal of asymptomatic impacted lower third molars. Int J Oral Maxillofac Surg 37:29-35, 2008 Reprints available from C Gay-Escoda, Centro Me´dico Teknon, Vilana 12, 08022 Barcelona, Spain; fax: þ34 93 402 42 12; e-mail: cgay@ ub.edu
EXTRACTS GOING GREEN—AVOCADOS, THAT IS The phytochemicals found in Hass avocados appear to have anticancer effects. Published in Seminars in Cancer Biology, a study found that these phytochemicals target several signaling pathways and raise the level of reactive oxygen in cancer cells. The result is cell death in the targeted cell lines, preventing precancerous cells from developing into cancer. [Avocados May Prevent Oral Cancer. AGD Impact December 2007, p 21]
EXTRACTS BRAIN BUILDING A paper published online by the Alzheimer’s and Dementia journal reports a significant decline in thinking and memory problems in men and women over age 70 compared to test results from 2002. Factors that seem to boost brain health include more years of schooling, higher income, and better cardiovascular health. ‘‘What’s bad for your heart is also bad for your brain,’’ says lead author Dr. Kenneth M. Langa of the University of Michigan. So keep your blood pressure and cholesterol in check and stay physically active if you want to have a healthy brain. [Getting Sharper. AARP Bulletin, April 2008]
Volume 53
Issue 5
2008
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232
Dental Abstracts
decision was significantly related to the estimated probability of pathology if extraction was not performed. The factors affecting the extraction decision were (in descending order of influence) estimated risk of complications, molar inclination, age, degree of impaction, and gender of patient. The evaluators showed no statistically significant differences in their decisions to extract or their estimated risk of complications relative to their experience. Prophylactic removal was likely chosen based on the clinical relevance of cyst formation or root resorption rather than on the actual prevalence of these complications. Oral surgeons tended to rely more heavily on the estimated risk of pericoronitis, whereas general dentists were more likely to be swayed by the estimated risk of periodontal lesions. The high estimated probability that any pathologic conditions would develop may be related to the fact that 70% of the teeth were found in patients under age 30 years. Professionals were inclined to remove distoangular molars with partial mucosal coverage in patients aged 19 to 25 years and horizontal teeth with partial or total mucosal coverage in patients aged 19 to 40 years. The risks of caries and periodontal damage with mesioangular and horizontal impaction were 48.42% and 60.76%, respectively. Root resorption of the second molar occurs in horizontal and mesioangular third molars with total bony coverage and was noted in 25% of the molars located in these positions; its estimated mean risk was 25.56%. Discussion.—The existing body of clinical and scientific evidence has provided the basis for determining the treatment of asymptomatic impacted third molars. Partial mucosal coverage tends to lead to infectious complications; mesioangular and horizontal positions are linked to caries, root resorption, and periodontal disorders of the distal surface of the second molar. Bacterial invasion is stymied by total mucosal and bony coverage. The partial retention of mucosal tissues yields a greater risk of complications. Patient age influences prognosis, with greater morbidity seen in older patients. The problems inherent to surgical removal can be minimized by taking care during tissue manipulation, giving analgesia and anti-inflammatory medication, and emphasizing patient adherence to the postoperative directions. The patient’s systemic condition should be carefully assessed to predict the development of bleeding and infectious complications.
Clinical Significance.—Reported here, the decision to extract, or not, otherwise asymptomatic impacted lower third molars, traditionally justified by claims of thwarting future morbidity, has apparently rested more on subjective appraisals than objective criteria. No long-term, controlled studies of extraction versus monitoring for these situations exist but are needed. How to design such a study is an ethical challenge.
Almendros-Marque´s N, Alaejos-Algarra E, Quinteros-Borgarello M, et al: Factors influencing the prophylactic removal of asymptomatic impacted lower third molars. Int J Oral Maxillofac Surg 37:29-35, 2008 Reprints available from C Gay-Escoda, Centro Me´dico Teknon, Vilana 12, 08022 Barcelona, Spain; fax: þ34 93 402 42 12; e-mail: cgay@ ub.edu
EXTRACTS GOING GREEN—AVOCADOS, THAT IS The phytochemicals found in Hass avocados appear to have anticancer effects. Published in Seminars in Cancer Biology, a study found that these phytochemicals target several signaling pathways and raise the level of reactive oxygen in cancer cells. The result is cell death in the targeted cell lines, preventing precancerous cells from developing into cancer. [Avocados May Prevent Oral Cancer. AGD Impact December 2007, p 21]
EXTRACTS BRAIN BUILDING A paper published online by the Alzheimer’s and Dementia journal reports a significant decline in thinking and memory problems in men and women over age 70 compared to test results from 2002. Factors that seem to boost brain health include more years of schooling, higher income, and better cardiovascular health. ‘‘What’s bad for your heart is also bad for your brain,’’ says lead author Dr. Kenneth M. Langa of the University of Michigan. So keep your blood pressure and cholesterol in check and stay physically active if you want to have a healthy brain. [Getting Sharper. AARP Bulletin, April 2008]
Volume 53
Issue 5
2008
233