Mandibular third molar guidelines: an international perspective

Abstract

When recommendations are made, with regard optimising the quality of patient care, evidence-based medicine should be applied and disseminated. Unfortunately despite undertaking dental extractions so frequently there is an embarrassing paucity of clinical evidence relating to this practice. In addition, our regulators provide numerous standards — do they use terminology consistently? Do the words ‘must’ and ‘should’ be synonymous or mean always and ideally? It transpires that our regulatory bodies use these terms differently. Guidelines can be a very useful support of optimal evidence based practice for clinicians and patients in clinical decision-making where the evidence may exist. They are mainly used o promote optimal patient care but may be used politically for cost-effectiveness stipulating setting for the surgery for example or the selection of anaesthesia. In 1979, the National Institutes of Health in the United States of America issued their guidelines on the management of third molars, partly as a result of critique by medical insurance companies, that third molars where being removed unnecessarily without any evidence-based clinical indication, resulting in high morbidity and cost. The National Institute of Clinical Excellence (NICE) introduced a technical assessment guidance (not guidelines) relating to TMS in 2000, discouraging the prophylactic removal of mandibular wisdom teeth (mandibular third molars [M3Ms]). However, there is growing evidence that this may not be in the best interest of the patient resulting in delay of inevitable surgery with additional damage to the adjacent second molars and resultant patient harm. In 1991, the American Association of Oral and Maxillofacial Surgeons (AAOMS) introduced their guide and parameters of care document and later, in 2012, a consultation workshop undertaken in Washington which included representation from the United Kingdom (Professor Tara Renton) and Finland (Professor Irja Venta), which was published in 2014 as AAOMS White paper for management of third molars. More recently AAOMS have revisited their M3M guidelines in the light of significant criticisms by the American Society of Public Health resulting in the introduction of active surveillance for patients with M3Ms without indications for surgery. The AAOMS paper, which is endorsed by British Association of Oral and Maxillofacial Surgeons, states that: Predicated on the best evidence-based data, third molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed. In the absence of disease or significant risk of disease, active clinical and radiographic surveillance is indicated. This statement clearly recognises that while not all third molars require surgical management, given the documented high incidence of problems associated with third molars over time, all patients should be evaluated by someone experienced and expert in third molar management. In reality the evidence base for M3M surgery is sparse and does not provide robust justification for existing Guidelines hence the variation and conflicting recommendations.