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Controversy, Evidence, and Third Molar Management

      Given the prevalence of third molars, high incidence of associated pathology, and cost of care (surgical or active surveillance), decision-making and management strategies for third molars have received a great deal of attention. Understandably, there are controversies that surround wisdom teeth, including the optimal time for treatment, if and when to prescribe medications such as antibiotics, steroids, and analgesics, the actual costs (financial and otherwise) of treatment and retention, and what constitutes monitoring of retained teeth. The “gorilla in the room,” however, involves what are appropriate indications for the removal of third molars, particularly those that are asymptomatic. The debate has intensified as proponents of retaining asymptomatic third molars have focused their concerns on cost containment (Fig. 1).
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      Fig. 1A 16-year-old girl with 4 unerupted and asymptomatic third molars. Clinical examination is necessary to help ascertain physiologic space for eruption and maintenance of these teeth, including quantity and quality of available space. Informed discussion should include possible consequences of surgical management as well as retention, and the impact of age on risks of treatment.
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      References

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        J Oral and Maxillofacial Surg. 2012; (Dentoalveolar Surgery Version 5.0, DEN 1) (for publication in 2012)
      2. National Institute of Clinical Excellence (N.I.C.E.) on the indications for the removal of third molars. Online: issued March 27, 2000. Available at: www.nice.org.uk. Accessed March, 2000.

      3. Mettes DT, Nienhuijs MM, van der Sanden WJ, et al. Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. Published online: issued October 8, 2008. Available at: www.cochrane.org. Accessed June 13, 2012.

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        J Oral Maxillofac Surg. 2000; 58: 288
      4. Opposition to prophylactic removal of third molars (wisdom teeth). Policy Date: 10/28/2008, Policy Number: 20085, Online: Issued February 2008. Available at: www.apha.org. Accessed October, 2008.

      Further readings

      1. American Association of Oral and Maxillofacial Surgeons: report of a workshop on the management of patients with third molar teeth.
        J Oral Maxillofac Surg. 1994; 52: 1102
        • Bagheri S.C.
        • Khan H.A.
        Extraction versus non-extraction management of third molars.
        Oral Maxillofac Surg Clin North Am. 2007; 19: 15
        • Blakey G.H.
        • Parker D.W.
        • Hull D.J.
        • et al.
        Impact of removal of asymptomatic third molars on periodontal pathology.
        J Oral Maxillofac Surg. 2009; 67: 245
        • Camilla-Tulloch J.F.
        • Antczak-Bouckoms A.A.
        • Wilkes J.W.
        The application of decision analysis to evaluate the need for extraction of asymptomatic third molars.
        J Oral Maxillofac Surg. 1987; 45: 855
        • Flick W.
        The third molar controversy: framing the controversy as a public health policy issue.
        J Oral Maxillofac Surg. 1999; 57: 438
        • Fisher E.L.
        • Garas R.
        • Blakey G.
        • et al.
        Changes over time in the prevalence of caries experience or periodontal pathology on third molars in young adults.
        J Oral Maxillofac Surg. 2012; 70: 1016
        • Giglio J.A.
        • Gunsolley J.C.
        • Short K.
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        Effect of removing impacted third molars on plaque and gingival indices.
        J Oral Maxillofac Surg. 1994; 52: 584
        • Haug R.H.
        • Perrott D.H.
        • Gonzalez M.L.
        • et al.
        The American Association of Oral and Maxillofacial Surgeons Age-Related Third Molar Study.
        J Oral Maxillofac Surg. 2005; 63: 1106
        • Knutsson K.
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        • et al.
        Asymptomatic mandibular third molars: oral surgeons' judgment of the need for extraction.
        J Oral Maxillofac Surg. 1992; 50: 329
        • Kugelberg C.F.
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        • et al.
        Periodontal healing after impacted third molar surgery in adolescents and adults.
        Int J Oral Maxillofac Surg. 1991; 20: 18
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        Risks and benefits of removal of impacted third molars: a critical review of the literature.
        Int J Oral Maxillofac Surg. 1992; 21: 17
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        • Fisher E.
        • et al.
        Third molars and periodontal pathologic findings in middle-age and older Americans.
        J Oral Maxillofac Surg. 2009; 67: 2592
        • Osborn T.P.
        • Frederickson G.C.
        A prospective study of complications related to mandibular third molar surgery.
        J Oral Maxillofac Surg. 1985; 43: 767
        • Rafetto L.
        Removal of asymptomatic third molars: a supporting view.
        J Oral Maxillofac Surg. 2006; 65: 1811