Management of 3rd Molar Flashcards
What is an impacted tooth?
An impacted tooth is one which is prevented from reaching the normal position by the presence of other structures - usually adjacent tooth, but may include ascending ramus or overlying soft tissues
How many wisdom teeth are extracted surgically annually?
80000
What problems are associated with 3rd molars?
Abnormal position - cheek biting 8/8
Caries, pulp and periapical pathology in the 2nd and 3rd molars
Periodontal problems
Pericoronitis
Resorption - internal and external for 7/7
Cyst formation
Difficulty with OH and food packing
Crowding of lower incisors? - not true
Often involved in line of mandibular fractures
In the way of orthognathic surgery
Potential risk in future for vulnerable and medically compromised pts (blood supply poorer, atrophic mandible)
Can wisdom teeth make your lower incisors crowded?
No
What is pericoronitis?
Inflam in soft tissues around the crown of a partially erupted tooth
Caused by bac infec and/or trauma
What is the most common reason for extraction of 8s?
Most commonly cited reason for extraction of 8s is pericoronitis
Pericoronitis symptoms?
Pain/discomfort
Soft tissue swelling in the region of the partially erupted tooth
Difficulty eating, swallowing or opening mouth
Tenderness on closing if opposing tooth in contact with inflamed soft tissues
Unpleasant taste or smell
Unwell - pyrexia
May be a recurring problem
Signs of pericoronitis?
Inflammation in soft tissues around crown of partially erupted tooth • Localised intra-oral swelling • Evidence of trauma from opposing tooth? • Pus +/- • Local lymphadenopathy +/- • Facial swelling +/-
Management of pericoronitis?
Local measures:
• Irrigation beneath gum flap with:
• Saline, Chlorhexidine mouthwash.
• Remove upper 8 if traumatic occlusion
• Advise HSMW / Chlorhexidine and analgesics
» +/-
• Antibiotics if spreading infection or medically compromised (steroids etc)
• Usually Metronidazole, 200mg t.d.s (as targets anaerobic bacteria)
• Drain pus if present
• Formal review ?
Management of pericoronitis at review?
Assess outcome of tx and manage appropriately
Assess 3rd molars
- Likely to erupt and be functional - monitor
- Unlikely to erupt - if problematic - consider removal, if not then leave and monitor
- Persistent, recurrent or severe problems - consider removal
What are the NICE guidelines on the removal of wisdom teeth?
Routine practice of prophylactic removal of pathology-free impacted 3rd molars should be discontinued in the NHS
Removal - limited to pts with evidence of pathology
Surgical removal limited to pts with evidence of pathology
Plaque formation is a risk factor but is not in itself an indication for surgery
History and justification documented
NICE guidelines for pericoronitis?
The degree to which the severity or recurrence rate of pericoronitis should influence the decision for surgical removal remains unclear
1st episode not an indication for surgery
2nd or subsequent episodes should be considered appropriate indications for surgery
Rationale for NICE guidelines?
Save 5 million a yr if prophylactic removal of 3rd molars discontinued
Pts on waiting list reduced
Not ethical to expose pts to unnecessary procedures
Justification for prophylactic removal?
Prevent crowding
Reduce complications in older individuals
Better able to cope when young (more complications when older and more difficult as denser bone)
If a GA then do all at once
What did a cochrane review find in clinical effectiveness and cost effectiveness in extraction and removal of 8s?
No difference in clinical effectiveness and cost-effectiveness between removal and retention
= No evidence to support or refute the benefits of prophylactic 3rd molar removal other than the prevention of late lower incisor crowding
