The management of the asymptomatic, disease-free wisdom tooth: removal versus retention.

The management of impacted third molars (M3s) or wisdom teeth is a decision encountered by oral and maxillofacial surgeons (OMSs) daily. The decision-making is usually very straightforward, owing to the presence of disease. A challenging management decision is how to manage the asymptomatic, disease-free wisdom tooth. For these types of M3s, the treatment is essentially a binary choice: (1) operative treatment (eg, extraction) or (2) retention. Management (ie, extraction versus retention) of the asymptomatic, disease-free wisdom tooth is fiercely controversial, with avid proponents of each treatment option. Because of the risk of future disease, the American Association of Oral and Maxillofacial Surgeons historically advocated “... that wisdom teeth be removed by the time the patient is a young adult to prevent future problems and to ensure optimal healing.” The American Public Health Association (APHA) rejects this strategy. APHA “opposes prophylactic removal of third molars, which subjects individuals and society to unnecessary costs, avoidable morbidity, and the risks of permanent injury.” However, the management of most asymptomatic, disease-free wisdom teeth lies somewhere between these two polar views. The author recommends that wisdom teeth be evaluated by the time the patient is a young adult to ensure optimal, patient-oriented management. The traditional evidence-based tool to address a clinical dilemma is the critical appraisal exercise (CAE). The CAE has 4 elements: (1) asking a relevant clinical question, (2) reviewing the literature, (3) assessing the validity of the best information available and answering the clinical question, and (4) applying the findings to enhance patient care. The relevant clinical question for this article is: Among patients with asymptomatic, disease-free M3s, do those patients who choose to retain their M3s, when compared with those who elect M3 removal, have “better” or “different” outcomes? “Better” outcomes primarily include avoiding the costs and risks of an operation. These outcomes, however, are short-term benefits. There are no guarantees that avoiding an operation today assures no operation in the future. As such, the short-term benefits of M3 retention are tempered by the tangible, but unknown, risk for M3 removal at some point in the patient’s lifetime with its associated costs and risks. In executing the second and third steps of the CAE, namely, reviewing and assessing the literature, the author identified a Cochrane systematic review that addressed the clinical question. The reviewers concluded that “no evidence was found to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth in adults.” Well-meaning advocates of both management strategies have used this review to support their positions. The final step of the CAE is to apply the findings to provide and enhance patient care. However, in the absence of good evidence to support either management position as the predominant strategy, what is the clinician (or policy maker or payor) to do? Evidence-based clinical decision-making is not using the best theoretical evidence to make decisions. For example, without one or more randomized clinical trials, Cochrane reviewers commonly conclude that no recommendation can be made owing