The third molar controversy: Framing the controversy as a public health policy issue

Purpose: This article summarizes the current research available concerning the removal of impacted third molars, and provides a background from which practitioners, public health policy advocates, and third-party payers can more objectively assess the the issues of appropriateness of care and overutilization of third molar surgery. Materials and Methods: A literature review was undertaken, with emphasis on noninterventional outcome studies and studies using statistical modeling techniques. Results: The health care resources being devoted to the removal of third molars are in the billions of dollars. There is an attempt at limiting these expenditures by third-party payers. These attempts have focused on the prophylactic removal of asymptomatic third molars. Some sources label the procedure as unnecessary surgery. Analysis of the literature does not answer this question with any degree of confidence. Conclusion: There appears to be a need for large population-based studies to provide practitioners with data to help them decide when intervention is indicated and when it is not. There is little agreement on how many third molars are being removed for so-called prophylactic reasons. The studies that are available on the nonintervention course are few and have significant flaws. The studies that argue against prophylactic removal are largely based on statistical models. The application of these models as a basis for clinical decision making is questionable. The effects of provider supply and reimbursement must be considered as an integral part of the controversy.