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Third molars: not so NICE? risk factors for distal caries in mandibular second molars Amir Treifi Jessica Cooper Julian Yates Dental Update 2024 50:2, 707-709.
Authors
AmirTreifi
BDS, MFDS RCPS(Glasg)
Dental Core Trainee in Oral Surgery, University Dental Hospital of Manchester
UK guidelines currently advise against the prophylactic removal of mandibular third molars. However, growing evidence shows that asymptomatic impacted mandibular third molars may contribute to the formation of distal caries in mandibular second molars. Patients should be made aware that these guidelines do not necessarily prevent the potential development of decay or loss of mandibular second molars. A retrospective review, over 6 months, analysed the incidence and evaluated the risk for developing caries on the distal aspect of mandibular second molars, in patients referred for assessment of impacted third molars. Distal caries in the mandibular second molar was present in 24.1% of cases. Of these patients, 9% demonstrated caries bilaterally. In those who developed distal caries in the mandibular second molar, 76% of adjacent third molars demonstrated mesio-angular impaction, 91% of third molars were partially erupted, and 95% of third molars were either touching or in close proximity to the ACJ of the second molar tooth. The prophylactic removal or coronectomy of mesio-angluar or horizontally impacted third molars that are partially erupted and closely related to the ACJ of mandibular second molars may result in improved long-term patient outcomes.
CPD/Clinical Relevance: The prophylactic removal or coronectomy of certain third molars may result in improved long-term patient outcomes.
Article
In 2000, the National Institute for Health and Clinical Excellence (NICE) first introduced their guidance on the extraction of mandibular third molar teeth.1 This guidance states that the removal of these teeth should be limited to those displaying certain symptoms, thus discouraging the prophylactic removal of pathology-free third molars. This guidance still stands over 20 years later.
Partially erupted and impacted mandibular third molar teeth present a challenging environment for oral hygiene; most notably with mesio-angular impaction against the amelocemental junction (ACJ) of the adjacent second molar. There is growing evidence to suggest that this increases the risk of caries development on the distal aspect of the mandibular second molar.2,3,4,5 This risk is heightened by several factors, including the angulation of impaction and the proximity to the ACJ of the second molar.6 Furthermore, there is evidence to suggest that patients with a low risk of developing caries are still susceptible to the development of distal caries in mandibular second molar teeth.2 Once present, the management of these carious lesions is often challenging because effective caries removal and restoration of the tooth is regularly impeded by the adjacent impacted third molar. Furthermore, as these lesions are often diagnosed at a late stage, and restoration is not always possible, patients are often subjected to extraction of the carious second molar, frequently alongside the removal of the impacted third molar. This then leads to the patient undergoing the removal of two, or potentially four teeth, if the decay has occurred bilaterally.
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