Parameters of care for patients undergoing mandibular third molar surgery 2020 Faculty of Dental Surgery The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields London WC2A 3PE T: 020 7869 6810 E: [email protected] W: www.rcseng.ac.uk © 2018 The Royal College of Surgeons of England Registered charity number 212808 2 Contents Guideline development .................................................................................................... 4 Executive summary ............................................................................................................ 8 Background ........................................................................................................................ 14 Definitions in oral surgery ........................................................................................... 24 Preoperative risk assessment ..................................................................................... 27 Risks versus benefits ...................................................................................................... 29 Therapeutic indications ................................................................................................ 32 Timing of surgery ............................................................................................................ 36 Adjunctive medical care for M3M surgery .............................................................. 38 Types of actions or interventions for M3Ms .......................................................... 42 Surgical techniques to minimise complications ................................................... 46 Main research questions arising ................................................................................ 49 Summary and conclusion .............................................................................................. 50 References .......................................................................................................................... 51 Appendix 1: Microbiology considerations .............................................................. 61 Appendix 2: Periodontal considerations................................................................. 67 Appendix 3: Long-term development of M3M associated disease ................. 71 Appendix 4: Modifying factors for patients requiring special care ............... 75 Appendix 5: Radiological considerations................................................................ 78 Appendix 6: The risk of retaining M3Ms ................................................................. 89 Appendix 7: Considerations in prescribing coronectomy ................................. 93 Appendix 8: Quality indicators for M3M surgery ................................................. 97 Appendix 9: Restorative considerations ...............................................................103 3 Guideline development Guideline development Guideline development group Tara Renton Chair Paul Coulthard Oral surgery Geoff Chiu Oral and maxillofacial surgery Selina Master and Vanita Brookes Special care dentistry Nikki Atack Orthodontics Paul Weston Periodontics Nicholas Drage Radiology Karun Dewan and Karl Bishop Restorative dentistry Edward Odell Oral and maxillofacial pathology Andrew Smith Oral microbiology There was also consultation with: Pearse Stinson, Faculty of General Dental Practice (UK) Christopher Bell, specialist in oral surgery, external reviewer Jenny Gallagher, Public Health England In addition, the input, advice and involvement in the final completion of the document, is acknowledged and appreciated from the following: Dr Obi Egbuniwe, Keith Horner and Selina Master. Intended audience All clinicians managing (and patients involved in) mandibular third molar (M3M) surgery Statement of conflict of interest The Faculty of Dental Surgery (FDS) is funded by its fellows and members, and no contributors are paid for their work on a guideline. Background A review of the guidelines was necessary because evidence suggests increasing patient harm due to retention of M3Ms. Based on the available evidence, consideration of clinical review is recommended, together with therapeutic, prophylactic and interventional surgery for patients, when appropriate. This approach is summarised in Appendix 10 and an executive summary is provided. 4 Guideline development Aims and objectives To describe appropriate care based on the best available scientific evidence and broad consensus To reduce inappropriate variation in practice To provide a more rational basis for referral To provide a focus for continuing education To promote efficient use of resources To enable setting and monitoring of standards, including audit To act as a quality control with the aim of promoting clinical excellence To highlight shortcomings within existing literature and suggest appropriate future research Methodology The FDS Clinical Standards Committee invited representatives from all stakeholder groups to join a working group to review the clinical standards of care for patients with M3Ms. Each member of the working group was invited to undertake a rapid review of literature relevant to the management of patients undergoing third molar surgery and their specialty. A time restriction of six months between the initial and final (third) meeting for the literature searching and retrieval stages was set. It is acknowledged that the literature review and search term selection were not iterative processes, it is therefore possible that some relevant references may have been missed. The criteria for evidence level type are summarised below. Each member provided a synopsis of the evidence base relating to their specialty and participated in text reviews over the ensuing year, and a consensus was achieved regarding the main documentation. Classification of evidence levels (modified from Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, 2001) A Evidence based on meta-analyses of randomised controlled studies A2 Evidence based on one randomised controlled study B1 Evidence based on at least one well designed controlled study without randomisation or at least one well designed quasi-experimental study B2 Evidence based on well designed non-experimental descriptive studies (eg cross-sectional studies) C Evidence based on reports or opinions of groups of experts, consensus conferences and/or clinical experience of recognised authorities; case studies A classification by recommendation levels is arrived at based on the above criteria by consensus; account must also be taken of factors that will influence 5 Guideline development treatment, such as patient preference, clinical relevance and feasibility of application in the routine medical situation. Recommendations levels A Strong recommendation B Recommendation O Open recommendation It was agreed that the evidence level would be provided by the stakeholder with the specialist interest. Areas lacking in consensus have been discussed and the evidence level agreed by the taskforce. Plain language statement The working group has intended to follow the official guidelines of the Plain Writing Act of 2010 and the Plain English Campaign. Evaluation and updating The FDS parameters of care for patients undergoing M3M surgery will be revisited on a three-yearly basis by the FDS Clinical Standards Committee and sooner should significant evidence arise that requires guideline update. The various components of the evaluation of clinical practice guidelines would include: an assessment of awareness of the guideline an assessment of whether clinical practice has changed in line with the guideline’s recommendations an assessment of whether health outcomes have changed an assessment of the guideline’s impact on patients’ and clinicians’ knowledge and understanding Publication When final approval is given by the FDS Clinical Standards Committee, the guideline will be formatted to produce a PDF document. A printed version will only be available if specific funding has been provided for the purpose by a specialty association or other interested body. 6 Guideline development Dissemination In order to disseminate the guideline, the FDS will: publish the guideline on its Clinical Guidelines webpage copy the guideline and web link to the relevant specialty associations copy the guideline and web link to its regional and specialty advisors across the UK publicise the document in the Bulletin of the Royal College of Surgeons of England send a copy to the National Institute for Health and Care Excellence for publication on its website and inclusion in its search database send a copy to the British Dental Journal publicise the guideline via the FDS Twitter feed 7 Executive summary Executive summary Parameters of care for patients with M3Ms The National Institute for Health and Care Excellence introduced guidance relating to third molar surgery in 2000, discouraging the prophylactic removal of mandibular third molars (M3Ms). However, there is growing evidence that this may not be in the best interests of the patient, resulting in delay of inevitable surgery with additional damage to the adjacent second molar. This prompted the stakeholder group to review the Faculty of Dental Surgery’s guidelines based on the best available research evidence. The main reason for third molar disease and the subsequent removal of third molars is infection, whether it be pericoronitis, caries in the M3M or adjacent teeth, periapical disease