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Guidance on the extraction of wisdom teeth. Technology appraisal guidance (TA1).. 2000; https://www.nice.org.uk/guidance/ta1
McArdle L The prevention and management of distal cervical caries of the mandibular second molar. Dent Update. 2019; 46:406-410
Knutsson K, Brehmer B, Lysell L, Rohlin M Pathoses associated with mandibular third molars subjected to removal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996; 82:10-17 https://doi.org/10.1016/s1079-2104(96)80371-4
Allen RT, Witherow H, Collyer J The mesioangular third molar – to extract or not to extract? Analysis of 776 consecutive third molars. Br Dent J. 2009; 206 https://doi.org/10.1038/sj.bdj.2009.517
Toedtling V, Coulthard P, Thackray G Distal caries of the second molar in the presence of a mandibular third molar-a prevention protocol. Br Dent J. 2016; 221:297-302 https://doi.org/10.1038/sj.bdj.2016.677
McArdle LW, McDonald F, Jones J Distal cervical caries in the mandibular second molar: an indication for the prophylactic removal of third molar teeth? Update. Br J Oral Maxillofac Surg. 2014; 52:185-189 https://doi.org/10.1016/j.bjoms.2013.11.007
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Mallya S, Lam E2018

Third molars: not so NICE? risk factors for distal caries in mandibular second molars

From Volume 50, Issue 2, February 2023 | Pages 135-140

Authors

Amir Treifi

BDS, MFDS RCPS(Glasg)

Dental Core Trainee in Oral Surgery, University Dental Hospital of Manchester

Articles by Amir Treifi

Email Amir Treifi

Jessica Cooper

BDS, MFDS RCPS (Glasg)

BDS, DCT1

Articles by Jessica Cooper

Julian Yates

BSc, BDS, PhD, MFDS RCPS, FDS RCPS, FDS RCS

Professor of Oral and Maxillofacial Surgery, School of Dentistry, University of Manchester

Articles by Julian Yates

Abstract

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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