LONG-TERM OUTCOME OF RETAINED THIRD MOLARS IS UNKNOWN

This image was selected as a direct contrast to the cover image of the desert, as together they depict the dramatic effects of climate change on global environments and population health. In this photograph, people are standing on sand bags to prevent flooding in Bangladesh. The low-lying areas of the country are regularly flooded by the melting glaciers of the Himalayas. Residents of Bangladesh also suffer regularly from drought caused by warmer weather. Copyright by Orjan F. Ellingvag and Dagens Naringsliv. Printed with permission of Corbis.

In his essay, Friedman1 asserted that there is compelling evidence that prophylactic extraction of third molars is a significant public health hazard. This is a very strong statement, based on an apparently limited review of the literature. Many of Friedman’s references could be considered selective and do not necessarily reflect current thinking.

A white paper recently commissioned by the American Association of Oral and Maxillofacial Surgeons provided a comprehensive review of the scientific literature on third molars. The literature provided no reliable evidence for predicting which third molars will cause problems in the future (including infections, caries, damage to the second molars, and periodontal disease) and which will not.2

The dilemma for the oral and maxillofacial surgeon is the inability to predict future morbidity with retention of asymptomatic third molars. Recent literature on the microflora around unerupted third molars has shown a predominance of organisms implicated in periodontal disease, suggesting that periodontal disease may originate around the third molars and spread forward.3^–8

Friedman cited the policy of the United Kingdom’s National Institute for Clinical Excellence (NICE)9 and suggested that such policy may be appropriate for US government-funded health services. However, we note that the assessment report10 on which the guidance is based concluded that trials comparing prophylactic removal with management of deliberate retention are needed. It was also noted that the outcomes of third molar removal are mainly short-term events, whereas the outcomes associated with retention occur later in life and can only be fully measured with long-term follow-up.

We submit that the implementation of the NICE guidance may serve as a population-based experiment to evaluate the long-term outcome of retention of asymptomatic third molars. While we await the results of this experiment, in the United States, the establishment of a similar policy is unjustified and could potentially increase oral health morbidity, and possibly systemic morbidity.