Removal of wisdom teeth - guidance from NICE

Guidance on the removal of wisdom teeth

For Action by
	Health Authority Chief Executives - England and Wales
	NHS Trust Chief Executives - England and Wales
	PCG Chief Executives
	Local Health Group General Managers
	General Dental Practitioners - England and Wales
	NHS Executive Regional Directors

For Information
	Special Health Authority Chief Executives
	Community Health Councils England and Wales
	Commission for Health Improvement
	Local Clinical Governance Support Team
	Deans of Medical Schools in England and Wales
	Chief Medical, Nursing and Dental Officers in England and Wales
	NHS Director Wales
	Chief Executive NHS
	Medical Director & Head of NHS Quality - Wales
	Chief Pharmaceutical Officer - England and Wales
	Welsh Clinical Effectiveness Unit
	Representative bodies for Health Services, professional organisations and statutory bodies, Royal Colleges, health advocacy groups

This Guidance is written in the following context This guidance represents the view of the Institute's Appraisal Committee (see Appendix A), 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 appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Section 1 constitutes the Institute's Guidance on the removal of Wisdom Teeth. The remainder of the document provides information on the following:

1.		Guidance (I'w weld yn Gymraeg)
2.		Clinical Need
3.		Evidence
4.		Implications for the NHS
5.		Further research
6.		Implementation
7.		Clinical Audit Advice
8.		Review of Guidance
		Appendix A: Appraisal Committee
		Appendix B: Sources of Evidence
		Appendix C: Information for patients (I'w weld yn Gymraeg)

1	Guidance
	1.1	The routine practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS.
	1.2	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).
	1.3	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.
	1.4	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.
	Mae'r adran hon (adran 1) hefyd ar gael yn Gymraeg ar ein gwefan neu drwy gysylltu â 0541 555 455.

2	Clinical Need and Practice
	2.1	Permanent molar teeth normally erupt from the age of six onwards, with the third molars (wisdom teeth) being the last to erupt, usually between the ages of eighteen and twenty four years. Wisdom teeth may erupt normally into correct dental alignment and function or conversely develop in non- or minimally functional positions. Impaction occurs when there is prevention of complete eruption due to lack of space, obstruction or development in an abnormal position. This may result in a tooth erupting partially or not at all. Wisdom teeth can also be impacted, either erupting partially or not at all. Impaction may be associated with pathological changes including pericoronitis, an increased risk of caries and periodontal disease in adjacent teeth, and orthodontic problems in later life.
	2.2	Removal of wisdom teeth is one of the most common surgical procedures performed in the UK. Current practice includes both the removal of impacted third molars causing pathological changes as well as the early prophylactic removal of pathology-free impacted third molars. Wide variations in the rates of this latter procedure across the country, of between 22% and 44%, were reported in a 1995 audit. However, in recent years, changes in the practice of removal of wisdom teeth may have taken place in response to Faculty of Dental Surgery, Royal College of Surgeon's guidelines, published in 1997.1 In England, in 1998/99, there were approximately 50,000 finished consultant episodes for surgical removal of impacted wisdom teeth. In Wales, in 1998/99, there were up to 3000 such procedures. It is estimated that the total cost to the NHS in England and Wales of wisdom teeth extractions is up to £12 million per year.

3	Evidence
	3.1	There is no reliable research evidence to support a health benefit to patients from the prophylactic removal of pathology-free impacted third molar teeth.
	3.2	Every procedure for the removal of an impacted third molar carries risk for the patient, including temporary or permanent nerve damage, alveolar osteitis, infection and haemorrhage as well as temporary local swelling, pain and restricted mouth opening. There are also risks associated with the need for general anaesthesia in some of these procedures, including rare and unpredictable death. Such patients are therefore being exposed to the risk of undertaking a surgical procedure unnecessarily.
	3.3	A list of the source documentation and opinion made available to the Appraisal Committee is attached as Appendix B.

4	Implications for the NHS
	4.1	Given the uncertainty in current rates of prophylactic removal of pathology-free impacted third molars, it is difficult to precisely quantify the budget impact of discontinuation of this practice. However, based on 1994/95 data, there would be an opportunity to release capacity in the specialty with a value of up to £5 million (NHS in England & Wales).
	4.2	The number of patients waiting for this operation, in England and Wales might change, if waiting lists are reviewed using this guidance.

5	Further Research
	5.1	There are two ongoing randomised controlled trials (in the United States and in Denmark) comparing prophylactic extraction of wisdom teeth with management by deliberate retention. The results of these trials will be reviewed by the Institute to establish whether they have a material impact on this guidance.

6	Implementation
	6.1	NHS trusts and dental practitioners should review their current practice against this guidance and use the audit advice set out below to prospectively collect data on individual practitioners' performance.
	6.2	The position of individual patients, currently scheduled for extraction of wisdom teeth, should be reviewed. This may be possible through a case note review, but there may be circumstances in which patients will need to be invited to attend a review clinic.
	6.3	The patient information, attached to this guidance as Appendix C, can be drafted into local information leaflets and could also be used to help inform patients if it is necessary to issue invitations to attend review clinics.

7	Clinical Audit Advice
	7.1	To enable dental practitioners to audit their own compliance with this guidance, it is recommended that all those who perform wisdom teeth extraction, should routinely record the indication for surgery and the diagnosis (see 1.3).
	7.2	It is recommended that this information be incorporated into manual recording systems and consideration given to the establishment of appropriate categories in electronic record keeping systems in general practices and hospitals.
	7.3	Prospective clinical audit programmes should record the proportion of extractions adhering to the criteria described in this guidance. Such programmes are likely to be more effective in improving patient care when they form part of the organisation's formal clinical governance arrangements and where they are linked to specific post-graduate activities.

8	Review of Guidance
	8.1	This guidance will be reviewed in March 2003.

Andrew Dillon Chief Executive March 2000

Annex A
Appraisal Committee Members

Professor R. L. Akehurst Dean, School of Health Related Research Sheffield University Professor David Barnett (Chairman) Professor of Clinical Pharmacology University of Leicester Professor Sir Colin Berry Professor of Morbid Anatomy St Bartholomews and Royal London School of Medicine Professor Martin Buxton Director of Health Economics Research Group Brunel University Professor Yvonne Carter Professor of General Practice and Primary Care St Bartholomews and Royal London School of Medicine Dr Karl Claxton Lecturer in Economics University of York Professor Duncan Colin-Jones Professor of Gastroenterology University of Southampton Ms Sarah Cowley Professor of Community Practice Development Kings College, London Dr Nicky Cullum Reader in Health Studies University of York Mr Chris Evennett Chief Executive Mid-Hampshire Primary Care Group Ms Jean Gaffin Formerly Executive Director National Council for Hospice and Specialist Palliative Care Service Mrs Sue Gallagher Chief Executive Merton, Sutton and Wandsworth Health Authority Dr Trevor Gibbs International Medical Operations Director Glaxo-Wellcome R&D Ltd Dr Sheila Bird MRC Biostatistics Unit, Cambridge Mr John Goulston Director of Finance The Royal Free Hampstead NHS Trust Professor Philip Home Professor of Diabetes Medicine University of Newcastle Dr Terry John General Practitioner St James Health Centre, London Dr Diane Ketley Clinical Governance Programme Leader Leicester Royal Infirmary Dr Mayur Lakhani General Practitioner, Highgate Surgery, Leicester and Lecturer, University of Leicester Mr M Mughal Consultant Surgeon Chorley and South Ribble NHS Trust Mr James Partridge Chief Executive Changing Faces Dr L.J. Patterson Consultant Physician and Medical Director Burnley General Hospital Professor Philip Routledge Professor of Clinical Pharmacology University of Wales Professor Andrew Stevens Professor of Public Health University of Birmingham

Appendix B
Documentation and Opinion Available to the Appraisal Committee
i)	The following documentation was made available to the Appraisal Committee:
	a)	Assessment Report Song F, O'Meara S, Wilson P, Kliejnen J, Golder S. The effectiveness and cost effectiveness of the prophylactic removal of wisdom teeth. NHS Centre for Reviews and Dissemination, University of York; November 1999;
	b)	Professional/Specialist group submissions; The Faculty of Dental Surgery, The Royal College of Surgeons of England. Birmingham Dental Hospital British Dental Association British Medical Association Dentistry 2000 - The British Dental Industry Association Royal College of Nursing

ii)	The following experts were invited to make submissions to the Committee:
	a)	Mr David Kramer, Dental Surgeon & Principle, Marchgate Dental Practice.
	b)	Professor Robin Seymour, Head of Department of Restorative Surgery, Dental School, Newcastle upon Tyne.
	c)	Mr John Lowry, the Department of Maxillofacial Surgery at the Royal Bolton Hospital.

Appendix C
Wisdom Teeth Removal - Patient Notes
The patient information in this appendix has been designed to support the production of your own information leaflets; you can download it from our web site (www.nice.org.uk) it is available in English and Welsh. A printed version of this text is available in English/Welsh or English alone. If you would like copies of the leaflet please contact 0541 555 455, and ask for "Guidance on the Extraction of Wisdom Teeth - Information for Patients.

What is NICE Guidance?
The National Institute for Clinical Excellence (NICE) is a part of the NHS. It uses a team of experts who produce guidance for both the NHS and patients on medicines, medial equipment and clinical procedures. When the Institute evaluates these things, it is called an appraisal. Each appraisal takes around 12 months to complete and involves the manufacturers of the technology, patient groups and professional organisations. 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.

What are Wisdom Teeth and why are they operated on?
Adult teeth normally come through 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 can 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, a higher 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. There is no reliable evidence to suggest that operating on impacted wisdom teeth that are not causing problems has any benefit for the patient. In fact every operation has some risk.

What do NICE recommend about the removal of Wisdom Teeth?
Based on the evidence, NICE has recommended to the NHS that:
1.	Impacted wisdom teeth that are free from disease (healthy) should not be operated on. There are two reasons for this
	a)	There is no reliable research to suggest that this practice benefits patients
	b)	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.

2.	Patients who have impacted wisdom teeth that are not causing problems should visit their dentist for their usual check-ups.

3.	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.

What should I do?
If you, a member of your family, or someone you care for are having problems with their wisdom teeth you should discuss this advice with your dentist or surgeon.

Will NICE review its guidance?
Yes. The guidance will be reviewed in March 2003. There is further research underway in this area and results of this will be reviewed by NICE to decide if this guidance needs to be updated before 2003.

Further Information:
Further information on NICE, and the full guidance issued to the NHS is available on the NICE web site (www.nice.org.uk). It can also be requested from 0541 555 455. Mae'r daflen hon hefyd ar gael yn Gymraeg.