Ref: NICE 2000/003a Issued: 27 March 2000

NICE have today issued to the NHS their guidance on the removal of wisdom teeth The guidance has been sent to all dentists in England and Wales and to NHS Management and concludes that:

The routine practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS.
The standard routine programme of dental care by dental practitioners and/or paraprofessional staff, need be no different, in general, for pathology free impacted third molars (those requiring no additional investigations or procedures).
Surgical removal of impacted third molars should be limited to patients with evidence of pathology. Such pathology includes unrestorable caries, non-treatable pulpal and/or periapical pathology, cellulitis, abcess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumour, tooth/teeth impeding surgery or reconstructive jaw surgery, and when a tooth is involved in or within the field of tumour resection.
Specific attention is drawn to plaque formation and pericoronitis. Plaque formation is a risk factor but is not in itself an indication for surgery. The degree to which the severity or recurrence rate of pericoronitis should influence the decision for surgical removal of a third molar remains unclear. The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery.

The guidance has been supported by the Chief Dental Officers for both England and Wales who have written to all NHS dentists asking them to revise their practice.

Andrew Dillon, (Chief Executive of NICE) said, "The Institute's Appraisal Committee reached its decision after very careful consideration of the evidence and I would want dentists and oral surgeons to take it fully into account when exercising their professional judgement."

"Obviously there will be patients waiting for this operation now. We have therefore suggested to the NHS that patients who are currently waiting to have their wisdom teeth removed are reviewed by their dentist or surgeon. For the patient this may or may not mean a visit to the dentist. It may be possible for a decision to be taken by looking at the patient's record, however there may be circumstances in which the patient will need to attend a review clinic.

Professor Sir Michael Rawlins (Chair of NICE) said "Like other professionals, dentists and surgeons follow current best practice and always act in the interest of the patient. The guidance we have issued today means that no matter where you live, in England or Wales, your dentist or surgeon has access to the same information on what the NHS considers best practice in this area".

ENDS
Notes for Editors
1. NICE was asked to look at wisdom teeth removal and provide guidance to the NHS which will help dentists and surgeons decide when wisdom teeth should be removed. The guidance issued today is the result of that work.
2. Copies of the full guidance, information for patients and a summary of the evidence are available on the NICE web site (www.nice.org.uk).
3. The full Guidance and patient notes are also available from

Tel: 0541 555 455
Fax: 01623 724 524
Post: PO Box 777 London SE1 6XH
Email: doh@prologistics.co.uk
4. NICE has provided a patient version of its guidance to the NHS, the full text is available on the NICE web site (www.nice.nhs.uk)
Impacted wisdom teeth that are free from disease (healthy) should not be operated on. There are two reasons for this
There is no reliable research to suggest that this practice benefits patients
Patients who do have healthy wisdom teeth removed are being exposed to the risks of surgery. These can include, nerve damage, damage to other teeth, infection, bleeding, and, rarely, death. Also, after surgery to remove wisdom teeth, patients may have swelling, pain and be unable to open their mouth fully.
Patients who have impacted wisdom teeth that are not causing problems should visit their dentist for their usual check-ups.
Only patients, who have diseased wisdom teeth, or other problems with their mouth, should have their wisdom teeth removed. Your dentist or oral surgeon will be aware of the sort of disease or condition which would require you to have surgery. Examples include untreatable tooth decay, abscesses, cysts or tumours, disease of the tissues around the tooth or where the tooth is in the way of other surgery.
5. Each piece of NICE guidance has a review date - for Wisdom teeth the guidance will be reviewed in March 2003. However there is further research underway in this area. The results of this will be reviewed by NICE to decide if the guidance needs to be updated before this date.
  In arriving at its recommendation NICE taken into account published
data including: 1998, a survey of 181 consultants reporting, of 19,971 third molars referred to hospital for assessment, and subsequently removed, 43.9% were disease free; other reliable estimates (1993,95,96) suggesting rates of between 20 and 40% of prophylactic removal and one other report suggesting rates as low as 4% (1998). Notwithstanding some uncertainty in the current statistical base it is thought that implementing the NICE guidance could result in an opportunity to release capacity in the specialty with a value of up to £5 million (NHS in England & Wales), based on 1994/95 data alone. The NICE assessment report is published on the web site.
6. Reviewing patients who are waiting for wisdom teeth removal in the light of the NICE guidance may have an impact on waiting lists in this area. Although it is difficult to be specific because of uncertainty in current statistics, implementing the NICE guidance would result in an opportunity to release capacity in the specialty with a value of up to £5 million (NHS in England & Wales), based on 1994/95 data.

7.

 The Chief Dental Officers for both England & Wales have made it clear that they support the NICE guidance in this area and have asked dentists to revise their practice, in line with the NICE guidance. (CDO England Robin Wild - CDO Wales Paul Langmaid).
8. The guidance represents the view of the Institute's Appraisal Committee, which was arrived at after careful consideration of the available evidence. Health professionals are expected to take it fully into account when exercising their clinical judgement about the circumstances in which it is appropriate to consider the removal of wisdom teeth. This guidance does not, however, override the individual responsibility of health professionals to make the appropriate decisions in the circumstances of the individual patient, in consultation with the patient and their guardian or carer
9. The Chief Dental Officers have indicated that their departments will be monitoring finished consultant episode statistics and data held by the Dental Practice board on the extraction of third molars.

The guidance itself recommends that audit strategies are implemented at a local level to monitor the uptake of the NICE guidance and that the guidance should form part of local Clinical Governance arrangements. This will involve individual dental practitioners and trust hospitals; The Commission for Health Improvement will review the implementation of this guidance.
10. Adult teeth normally come through (erupt) from the age of 6 upwards, with the wisdom teeth being the last to arrive (usually between the ages of 18 & 24 years). Sometimes, as wisdom teeth come through they cause problems. The term used to describe those wisdom teeth that don't come through normally is impacted wisdom teeth. Two reasons for this are a lack of space, or other teeth being in the way. For most people, impacted wisdom teeth cause no problems at all, but some people can suffer problems such as inflammation of the surrounding gum, an increased risk of tooth decay, gum disease in other teeth, and possibly problems with teeth in later life.

Removal of wisdom teeth is one of the most common operations carried out in the UK. Impacted wisdom teeth have sometimes been removed whether or not they were causing problems. Every operation has some risk. For removal of wisdom teeth some of the risks are temporary or permanent nerve damage, damage to other teeth, infection and bleeding. There are also some risks in having a general anaesthetic. After surgery to remove wisdom teeth, patients may have swelling, pain and their mouth may not open fully.

11. The National Institute for Clinical Excellence was set up as a Special Health Authority on the 1st April 1999 and as such it is a part of the National Health Service (NHS).
12. There are three main strands to the work of the Institute: appraisals of health technologies, the development of clinical guidelines and the promotion of clinical audit.
13. Responsibility for selecting the guideline topics referred to the Institute rests with the Secretary of State for Health and the National Assembly for Wales