AAOMS white paper on third molars (2016): remove the ones with disease or a high risk of it, actively watch the rest, and decide before the middle of the third decade

What it says#

The white paper is two pages. It opens with the AAOMS's view that the best approach to a clinical dilemma is evidence-based practice: the best available clinically relevant evidence merged with a comprehensive clinical and imaging examination, producing recommendations the clinician can discuss with the patient. Third molars are named as a common dilemma: when surgery is indicated, especially for asymptomatic teeth; the risks of removal and of retention; the timing; the cost of treatment and of retention; and how to plan follow-up when a tooth is kept. It lists the recognized management choices as removal, partial removal (coronectomy), retention with active clinical and radiographic surveillance, surgical exposure, repositioning, transplantation, surgical periodontics, and marsupialization of associated soft tissue pathology with observation and possible secondary treatment.

Two sentences carry the position. 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. The paper adds that the statement recognizes that not all third molars require surgical management, but that given the documented high incidence of problems over time, all patients should be evaluated by someone experienced and expert in third molar management. It also states that evidence clearly indicates surgery is more difficult as patients age, so a decision should be made before the middle of the patient's third decade to remove or continue to observe, with the knowledge that future treatment may be necessary, and it recognizes the oral and maxillofacial surgeon as the clinician qualified to determine a surgical treatment plan.

The second page sets out the approach to the patient. It begins with a medical and dental history with attention to any symptoms, and whether they come from the third molars or another source. The physical examination covers eruption status and position, functionality, and periodontal and caries status. Imaging establishes the presence of the tooth and of disease, the anatomy of the tooth and its roots, and its relationship to the inferior alveolar nerve, the adjacent second molar and the maxillary sinus, and can detect associated and non-associated disease such as cysts or tumors. Where there is evidence of disease, management is generally straightforward; tissue suspected to be pathologic is submitted for histologic examination; where symptoms are present, the source is identified and managed. For asymptomatic, disease-free teeth the paper is candid about uncertainty: the future cannot be confidently predicted for every patient, so the clinician's experience in recognizing the likelihood of pathology, and the ability to communicate it in realistic terms, are what the patient relies on. In that case the surgeon reviews the likelihood of pathology developing, functionality, the risks of removal and of retention, and a protocol for active surveillance. Removal is favored when the tooth is or is likely to be non-functional, when there is an overlying removable prosthesis, when orthodontic removal is justified (as when the tooth is preventing eruption of the second molar), and with planned orthognathic surgery. Patients are told about the greater difficulty and complication rate of removal as they age, and, where appropriate, that if they keep their disease-free wisdom teeth it is possible they could live their entire lives without problems.

The companion Supporting Information document, also 2016, supplies the numbers. It lists the pathologies associated with retained third molars (caries, pericoronitis, root resorption, periodontitis, infections, cysts, tumors and mandible fractures) and the complications of removal. It cites two papers: a review of the United Kingdom's NICE guidelines finding that third molar removal, after an initial fall, became as common as before, with an older mean age at removal and reasons that shifted to caries, periodontal disease and pericoronitis; and a systematic review of prospective studies of at least 50 subjects with at least 12 months of follow-up, in which the mean incidence of extraction of previously asymptomatic retained third molars ranged from 5% at one year to 64% at 18 years. Among its twelve evidence-based facts: the absence of symptoms does not equate to the absence of disease; retained third molars frequently and unpredictably change position, eruption and periodontal status; probing depths over 4 mm at a third molar raise the risk of anterior pocketing; extraction reduces the risk of periodontal disease in young adults; and most patients with retained, asymptomatic, disease-free third molars eventually need surgical management. Its recommendations add that a completely erupted, functional, symptom-free, caries-free third molar in a hygienic position with a healthy periodontium does not require extraction but does require routine maintenance and periodic surveillance, and that an impacted tooth with complete roots, fully covered by bone, in a patient over 30 and without pathology can be maintained but monitored.

Who it applies to#

Every patient with a third molar, because the paper's first instruction is evaluation by someone expert in third molar management, and its workup (history, exam, imaging) is written for the general examination as much as for the surgical consult. The position then sorts teeth three ways: disease present, where management is straightforward; symptoms present, where the source is found first; and asymptomatic and disease-free, where the surgeon and the patient weigh the likelihood of pathology against the risks of surgery and choose surgery or surveillance.

It is not a rule that every third molar comes out, and it says so. It sets no interval for surveillance, only that a protocol exists and that the patient understands the commitment; the supporting document calls it a lifetime of follow-up. It is a professional position, endorsed by the organizations listed on it, not a payer policy, and it is about third molars only.

What changed#

The white paper's own framing is that the discussion of third molars had been obscured by unsupported statements and misinterpretation of the data, and the April 2016 announcement presented it as clear, evidence-based clinical guidance with eight dental specialties and three international oral surgery associations behind it. Against the two common positions, remove them all prophylactically or leave them until they hurt, the paper stakes out a third: manage disease and high risk surgically, watch the rest actively, and make the call young. The 2024 AAOMS clinical paper on impacted third molars keeps the same structure, listing indications for removal and allowing a fully bone-covered impacted tooth with complete roots to be maintained under monitoring.

Where the source is#

The link under the title opens the AAOMS's PDF of Management of Third Molar Teeth, the two-page white paper, copyright 2016, in the form posted on aaoms.org. Its companion, Supporting Information to the Management of Patients with Third Molar Teeth, is a three-page AAOMS PDF from January 2016 that carries the citations and the evidence-based facts summarized here; the April 20, 2016 news release, the 2010 summary of the AAOMS third molar clinical studies and the 2024 clinical paper on impacted third molars are listed above, all free on AAOMS sites. The organizations listed on the white paper as supporting it are the AAOMP, AAOMR, AAPD, AAP, AAE, AAO, ACOMS, BAOMS, BAOS, CAOMS and IAOMS; the news release names the American College of Prosthodontists as well. AAOMS reserves reproduction rights on both documents.